1
|
Dryden L, Song J, Valenzano TJ, Yang Z, Debnath M, Lin R, Topolovec-Vranic J, Mamdani M, Antoniou T. Evaluation of Machine Learning Approaches for Predicting Warfarin Discharge Dose in Cardiac Surgery Patients: Retrospective Algorithm Development and Validation Study. JMIR Cardio 2023; 7:e47262. [PMID: 38055310 PMCID: PMC10733832 DOI: 10.2196/47262] [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: 03/14/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Warfarin dosing in cardiac surgery patients is complicated by a heightened sensitivity to the drug, predisposing patients to adverse events. Predictive algorithms are therefore needed to guide warfarin dosing in cardiac surgery patients. OBJECTIVE This study aimed to develop and validate an algorithm for predicting the warfarin dose needed to attain a therapeutic international normalized ratio (INR) at the time of discharge in cardiac surgery patients. METHODS We abstracted variables influencing warfarin dosage from the records of 1031 encounters initiating warfarin between April 1, 2011, and November 29, 2019, at St Michael's Hospital in Toronto, Ontario, Canada. We compared the performance of penalized linear regression, k-nearest neighbors, random forest regression, gradient boosting, multivariate adaptive regression splines, and an ensemble model combining the predictions of the 5 regression models. We developed and validated separate models for predicting the warfarin dose required for achieving a discharge INR of 2.0-3.0 in patients undergoing all forms of cardiac surgery except mechanical mitral valve replacement and a discharge INR of 2.5-3.5 in patients receiving a mechanical mitral valve replacement. For the former, we selected 80% of encounters (n=780) who had initiated warfarin during their hospital admission and had achieved a target INR of 2.0-3.0 at the time of discharge as the training cohort. Following 10-fold cross-validation, model accuracy was evaluated in a test cohort comprised solely of cardiac surgery patients. For patients requiring a target INR of 2.5-3.5 (n=165), we used leave-p-out cross-validation (p=3 observations) to estimate model performance. For each approach, we determined the mean absolute error (MAE) and the proportion of predictions within 20% of the true warfarin dose. We retrospectively evaluated the best-performing algorithm in clinical practice by comparing the proportion of cardiovascular surgery patients discharged with a therapeutic INR before (April 2011 and July 2019) and following (September 2021 and May 2, 2022) its implementation in routine care. RESULTS Random forest regression was the best-performing model for patients with a target INR of 2.0-3.0, an MAE of 1.13 mg, and 39.5% of predictions of falling within 20% of the actual therapeutic discharge dose. For patients with a target INR of 2.5-3.5, the ensemble model performed best, with an MAE of 1.11 mg and 43.6% of predictions being within 20% of the actual therapeutic discharge dose. The proportion of cardiovascular surgery patients discharged with a therapeutic INR before and following implementation of these algorithms in clinical practice was 47.5% (305/641) and 61.1% (11/18), respectively. CONCLUSIONS Machine learning algorithms based on routinely available clinical data can help guide initial warfarin dosing in cardiac surgery patients and optimize the postsurgical anticoagulation of these patients.
Collapse
Affiliation(s)
| | | | | | - Zhen Yang
- Unity Health Toronto, Toronto, ON, Canada
| | | | | | | | | | | |
Collapse
|
2
|
Zhao L, Zhai Z, Li P. One Rare Warfarin Resistance Case and Possible Mechanism Exploration. Pharmgenomics Pers Med 2023; 16:609-615. [PMID: 37359384 PMCID: PMC10290475 DOI: 10.2147/pgpm.s404474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
One 59-year-old female patient with deep venous thrombosis (DVT) and pulmonary embolism (PE) was treated with 6 mg warfarin once daily as an anticoagulant. Before taking warfarin, her international normalized ratio (INR) was 0.98. Two days after warfarin treatment, her INR did not change from baseline. Due to the high severity of the PE, the patient needed to reach her target range (INR goal = 2.5, range = 2~3) rapidly, so the dose of warfarin was increased from 6 mg daily to 27 mg daily. However, the patient's INR did not improve with the dose escalation, still maintaining an INR of 0.97-0.98. We drew a blood sample half an hour before administering 27 mg warfarin and detected single nucleotide polymorphism for the following genes, which were identified to be relevant with warfarin resistance: CYP2C9 rs1799853, rs1057910, VKORC1 rs9923231, rs61742245, rs7200749, rs55894764, CYP4F2 rs2108622, and GGCX rs2592551. The trough plasma concentration of warfarin was 196.2 ng/mL after 2 days of warfarin administration with 27 mg QD, which was much lower than the therapeutic drug concentration ranges of warfarin (500-3,000 ng/mL). The genotype results demonstrate that the CYP4F2gene has rs2108622 mutation which can explain some aspect of warfarin resistance. Further investigations are necessary to fully characterize other pharmacogenomics or pharmacodynamics determinants of warfarin dose-response in Chinese.
Collapse
Affiliation(s)
- Li Zhao
- Pharmacy Department, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Zhenguo Zhai
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Pengmei Li
- Pharmacy Department, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| |
Collapse
|
3
|
Gao W, Zhang Z, Guan Z, Chen W, Li Z. Developing Chinese race-specific warfarin dose prediction algorithms. Int J Clin Pharm 2023:10.1007/s11096-023-01565-1. [PMID: 36991222 DOI: 10.1007/s11096-023-01565-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/24/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Numerous genotype-guided warfarin dosing algorithms have been developed to individualize warfarin doses, but they can only explain 47-52% of the variability. AIM This study aimed to develop new warfarin algorithms suitable to predict the stable warfarin dose for the Chinese population and to compare their prediction performance with those of the most commonly used algorithms. METHOD Multiple linear regression analysis with the warfarin optimal dose (WOD), logarithm (log) WOD, 1/WOD, and [Formula: see text], respectively, as the dependent variables were performed to deduce a new warfarin algorithm (NEW-Warfarin). WOD was the stable dose that maintained the international normalized ratio (INR) within the target range (2.0-3.0). Three major genotype-guided warfarin dosing algorithms were selected and compared against NEW-Warfarin predictive performance using the mean absolute error (MAE). Furthermore, patients were divided into five groups according to warfarin indications [atrial fibrillation (AF), pulmonary embolism (PE), cardiac-related disease (CRD), deep vein thrombosis (DVT), and other diseases (OD)]. Multiple linear regression analyses were also performed for each group. RESULTS The regression equation with [Formula: see text] as the dependent variable had the highest coefficient of determination (R2 = 0.489). The NEW-Warfarin had the best predictive accuracy compared to the three algorithms selected. Group analysis, according to indications, showed that the R2 of the five groups were PE (0.902) > DVT (0.608) > CRD (0.569) > OD (0.436) > AF (0.424). CONCLUSION Dosing algorithms based on warfarin indications are more suitable for predicting warfarin doses. Our research provides a novel strategy to develop indication-specific warfarin dosing algorithms to improve the efficacy and safety of warfarin prescribing.
Collapse
Affiliation(s)
- Weiqi Gao
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 99 Longcheng Street, Taiyuan, 030032, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhijiao Zhang
- School of Pharmacy, Shanxi Medical University, Taiyuan, 030001, China
| | - Zhaobo Guan
- School of Pharmacy, Shanxi Medical University, Taiyuan, 030001, China
| | - Weihong Chen
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 99 Longcheng Street, Taiyuan, 030032, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhihong Li
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 99 Longcheng Street, Taiyuan, 030032, China.
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| |
Collapse
|
4
|
Calvert P, Tamirisa K, Al-Ahmad A, Lip GYH, Gupta D. Racial and Ethnic Disparities in Stroke Prevention for Atrial Fibrillation. Am J Med 2023; 136:225-233. [PMID: 36495932 DOI: 10.1016/j.amjmed.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
Racial and ethnic disparities in health care are well documented, although often underappreciated. In the setting of atrial fibrillation, stroke risk and severity may be higher in underrepresented ethnic populations. Additionally, the risk of bleeding is not uniform, and pharmacogenetics play an important role in anticoagulant therapy. In this narrative review, we discuss the complex issues surrounding stroke prevention in underrepresented ethnic groups with atrial fibrillation.
Collapse
Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | | | | | - Gregory Y H Lip
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom.
| |
Collapse
|
5
|
Sun B, Yew PY, Wen YF, Chi CL, Straka RJ. Comparison of the Warfarin Dosing and Outcomes in Hmong Versus East Asians Patients: Real-World Data From an Integrated Healthcare System. Cureus 2022; 14:e28905. [PMID: 36249660 PMCID: PMC9549258 DOI: 10.7759/cureus.28905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Background Previous research predicted that Hmong, an understudied East Asian subpopulation, might require significantly lower warfarin doses than East Asian patients partially due to their unique genetic and clinical factors. However, such findings have not been corroborated using real-world data. Methods This was a retrospective cohort study of Hmong and East Asian patients receiving warfarin. Warfarin stable doses (WSD) and time to the composite outcome, including international normalized ratio (INR) greater than four incidences or major bleeding within six months of warfarin initiation, were compared. Results This cohort study included 55 Hmong and 100 East Asian patients. Compared to East Asian patients, Hmong had a lower mean WSD (14.5 vs. 20.4 mg/week, p<0.05). In addition, Hmong had a 3.1-fold (95% CI: 1.1-9.3, p<0.05) higher hazard of the composite outcome. Conclusion Using real-world data, significant differences in warfarin dosing and hazard for the composite outcome of INR>4 and major bleeding were observed between Hmong and East Asian patients. These observations further underscore the importance of recognizing subpopulation-based differences in warfarin dosing and outcomes.
Collapse
|
6
|
Nicholson MW, Huang CY, Wang JY, Ting CY, Cheng YC, Chan DZH, Lee YC, Hsu CC, Hsu YH, Chang CMC, Hsieh ML, Cheng YY, Lin YL, Chen CH, Wu YT, Hacker TA, Wu JC, Kamp TJ, Hsieh PCH. Cardio- and Neurotoxicity of Selected Anti-COVID-19 Drugs. Pharmaceuticals (Basel) 2022; 15:ph15060765. [PMID: 35745684 PMCID: PMC9231250 DOI: 10.3390/ph15060765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 12/10/2022] Open
Abstract
Since December 2019, the novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected ~435 million people and caused ~6 million related deaths as of March 2022. To combat COVID-19, there have been many attempts to repurpose FDA-approved drugs or revive old drugs. However, many of the current treatment options have been known to cause adverse drug reactions. We employed a population-based drug screening platform using 13 human leukocyte antigen (HLA) homozygous human induced pluripotent cell (iPSC) lines to assess the cardiotoxicity and neurotoxicity of the first line of anti-COVID-19 drugs. We also infected iPSC-derived cells to understand the viral infection of cardiomyocytes and neurons. We found that iPSC-derived cardiomyocytes express the ACE2 receptor which correlated with a higher infection of the SARS-CoV-2 virus (r = 0.86). However, we were unable to detect ACE2 expression in neurons which correlated with a low infection rate. We then assessed the toxicity of anti-COVID-19 drugs and identified two cardiotoxic compounds (remdesivir and arbidol) and four neurotoxic compounds (arbidol, remdesivir, hydroxychloroquine, and chloroquine). These data show that this platform can quickly and easily be employed to further our understanding of cell-specific infection and identify drug toxicity of potential treatment options helping clinicians better decide on treatment options.
Collapse
Affiliation(s)
| | - Ching-Ying Huang
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Jyun-Yuan Wang
- Genomics Research Center, Academia Sinica, Taipei 115, Taiwan
| | - Chien-Yu Ting
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yu-Che Cheng
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Darien Z H Chan
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yi-Chan Lee
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Ching-Chuan Hsu
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yu-Hung Hsu
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Cindy M C Chang
- Cardiovascular Physiology Core Facility, Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Marvin L Hsieh
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
- Cardiovascular Physiology Core Facility, Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Yuan-Yuan Cheng
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yi-Ling Lin
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Chien-Hsiun Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Ying-Ta Wu
- Genomics Research Center, Academia Sinica, Taipei 115, Taiwan
| | - Timothy A Hacker
- Cardiovascular Physiology Core Facility, Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Timothy J Kamp
- Department of Medicine and Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Patrick C H Hsieh
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
- Department of Medicine and Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53705, USA
- Institute of Clinical Medicine, National Taiwan University, Taipei 106, Taiwan
| |
Collapse
|
7
|
Huang CY, Nicholson MW, Wang JY, Ting CY, Tsai MH, Cheng YC, Liu CL, Chan DZH, Lee YC, Hsu CC, Hsu YH, Yang CF, Chang CMC, Ruan SC, Lin PJ, Lin JH, Chen LL, Hsieh ML, Cheng YY, Hsu WT, Lin YL, Chen CH, Hsu YH, Wu YT, Hacker TA, Wu JC, Kamp TJ, Hsieh PCH. Population-based high-throughput toxicity screen of human iPSC-derived cardiomyocytes and neurons. Cell Rep 2022; 39:110643. [PMID: 35385754 DOI: 10.1016/j.celrep.2022.110643] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/13/2022] [Accepted: 03/16/2022] [Indexed: 12/21/2022] Open
Abstract
In this study, we establish a population-based human induced pluripotent stem cell (hiPSC) drug screening platform for toxicity assessment. After recruiting 1,000 healthy donors and screening for high-frequency human leukocyte antigen (HLA) haplotypes, we identify 13 HLA-homozygous "super donors" to represent the population. These "super donors" are also expected to represent at least 477,611,135 of the global population. By differentiating these representative hiPSCs into cardiomyocytes and neurons we show their utility in a high-throughput toxicity screen. To validate hit compounds, we demonstrate dose-dependent toxicity of the hit compounds and assess functional modulation. We also show reproducible in vivo drug toxicity results using mouse models with select hit compounds. This study shows the feasibility of using a population-based hiPSC drug screening platform to assess cytotoxicity, which can be used as an innovative tool to study inter-population differences in drug toxicity and adverse drug reactions in drug discovery applications.
Collapse
Affiliation(s)
- Ching Ying Huang
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | | | - Jyun Yuan Wang
- Genomics Research Center, Academia Sinica, Taipei 115, Taiwan
| | - Chien Yu Ting
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Ming Heng Tsai
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yu Che Cheng
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Chun Lin Liu
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Darien Z H Chan
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yi Chan Lee
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Ching Chuan Hsu
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yu Hung Hsu
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Chiou Fong Yang
- Institute of Applied Mechanics, National Taiwan University, Taipei 106, Taiwan
| | - Cindy M C Chang
- Cardiovascular Physiology Core Facility, Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Shu Chian Ruan
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Po Ju Lin
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Jen Hao Lin
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Li Lun Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Marvin L Hsieh
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan; Cardiovascular Physiology Core Facility, Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Yuan Yuan Cheng
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Wan Tseng Hsu
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Yi Ling Lin
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Chien Hsiun Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan
| | - Yu Hsiang Hsu
- Institute of Applied Mechanics, National Taiwan University, Taipei 106, Taiwan
| | - Ying Ta Wu
- Genomics Research Center, Academia Sinica, Taipei 115, Taiwan
| | - Timothy A Hacker
- Cardiovascular Physiology Core Facility, Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Timothy J Kamp
- Department of Medicine and Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Patrick C H Hsieh
- Institute of Biomedical Sciences, Academia Sinica, Taipei 115, Taiwan; Department of Medicine and Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53705, USA; Institute of Medical Genomics and Proteomics and Institute of Clinical Medicine, National Taiwan University, Taipei 106, Taiwan.
| |
Collapse
|
8
|
Fahmi AM, Elewa H, El Jilany I. Warfarin dosing strategies evolution and its progress in the era of precision medicine, a narrative review. Int J Clin Pharm 2022; 44:599-607. [PMID: 35247148 PMCID: PMC9200678 DOI: 10.1007/s11096-022-01386-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/09/2022] [Indexed: 11/30/2022]
Abstract
Background For decades, vitamin K antagonists and specifically warfarin, have been the sole agents used orally to manage thromboembolic conditions, including stroke and venous thromboembolism (VTE). Several factors lead to warfarin dose variability, including genetic and non-genetic factors which made warfarin management challenging especially at the initiation phase. To overcome the challenges with warfarin dosing at initiation, strategies other than conventional or fixed dosing were introduced and explored. Aim In this narrative review, we aim to discuss and critique the different dosing strategies for warfarin at initiation with more focus on genotype-guided warfarin dosing and the most recent supporting evidence for and against its use. Method Medline database was searched from 1965 to July 2021. Articles addressing different warfarin dosing methods were screened for inclusion. Results A number of methods exist for warfarin initiation. Studies comparing different dosing methods for initiation yielded conflicting outcomes due to differences in study design, population studied, comparator, and outcomes measured. Conclusions Looking at the big picture, the use of genetic dosing for warfarin initiation can lead to better outcomes. Whether these better outcomes are clinically or economically beneficial remains controversial.
Collapse
Affiliation(s)
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar.
| | | |
Collapse
|
9
|
Gross AS, Harry AC, Clifton CS, Pasqua OD. Clinical Trial Diversity: An Opportunity for Improved Insight into the Determinants of Variability in Drug Response. Br J Clin Pharmacol 2022; 88:2700-2717. [PMID: 35088432 PMCID: PMC9306578 DOI: 10.1111/bcp.15242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 11/27/2022] Open
Abstract
Although the number of countries participating in pivotal trials submitted to enable drug registration has nearly doubled over the past 25 years, there has not been a substantial increase in the diversity of clinical trial populations. In parallel, our understanding of factors that influence medicine response and variability has continued to evolve. The notion of intrinsic and extrinsic sources of variability has been embedded into different regulatory guidelines, including the recent guideline on the importance of enhancing the diversity of clinical trial populations. In addition to presenting the clinical and scientific reasons for ensuring that clinical trial populations represent the demographics of patient populations, this overview outlines the efforts of regulatory agencies, patient advocacy groups and clinical researchers to attain this goal through strategies to meet representation in recruitment targets and broaden eligibility criteria. Despite these efforts, challenges to participation in clinical trials remain, and certain groups continue to be underrepresented in development programmes. These challenges are amplified when the representativeness of specific groups may vary across countries and regions in a global clinical programme. Whilst enhanced trial diversity is a critical step towards ensuring that results will be representative of patient populations, a concerted effort is required to characterise further the factors influencing interindividual and regional differences in response for global populations. Quantitative clinical pharmacology principles should be applied to allow extrapolation of data across groups or regions as well as provide insight into the effect of patient‐specific characteristics on a medicine's dose rationale and efficacy and safety profiles.
Collapse
Affiliation(s)
- Annette S Gross
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline R&D, Sydney, Australia.,Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anya C Harry
- Global Demographics & Diversity, Global Clinical Sciences and Delivery, GlaxoSmithKline R&D, Upper Providence, USA.,Current Address: West Pharmaceutical Services, King of Prussia, USA
| | - Christine S Clifton
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline R&D, Sydney, Australia
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline R&D, Brentford, United Kingdom.,Clinical Pharmacology & Therapeutics Group, School of Pharmacy - University College London, London, UK
| |
Collapse
|
10
|
Suwanawiboon B, Rotchanapanya W, Mahaprom K, Thongnoppakhun W, Lalerd Y, Limwongse C, Sermsathanasawadi N, Owattanapanich W. The efficacy of low-dose warfarin initiation (3 mg versus 5 mg) in newly diagnosed venous thromboembolism patients among a population with a high prevalence of warfarin-sensitive haplotype of the VKORC1 gene: a randomized controlled trial. Hematology 2022; 27:95-104. [DOI: 10.1080/16078454.2021.2019891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Bundarika Suwanawiboon
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wannaphorn Rotchanapanya
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Komkrit Mahaprom
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanna Thongnoppakhun
- Division of Molecular Genetics, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yupaporn Lalerd
- Division of Medical Genetics, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanin Limwongse
- Division of Medical Genetics, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
11
|
Olafuyi O, Parekh N, Wright J, Koenig J. Inter-ethnic differences in pharmacokinetics-is there more that unites than divides? Pharmacol Res Perspect 2021; 9:e00890. [PMID: 34725944 PMCID: PMC8561230 DOI: 10.1002/prp2.890] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/19/2021] [Indexed: 12/31/2022] Open
Abstract
Inter-ethnic variability in pharmacokinetics (PK) has been attributed to several factors ranging from genetic to environmental. It is not clear how current teaching in higher education (HE) reflects what published literature suggests on this subject. This study aims to gain insights into current knowledge about inter-ethnic differences in PK based on reports from published literature and current teaching practices in HE. A systematic literature search was conducted on PubMed and Scopus to identify suitable literature to be reviewed. Insights into inter-ethnic differences in PK teaching among educators in HE and industry were determined using a questionnaire. Thirty-one percent of the studies reviewed reported inter-ethnic differences in PK, of these, 37% of authors suggested genetic polymorphism as possible explanation for the inter-ethnic differences observed. Other factors authors proposed included diet and weight differences between ethnicities. Most respondents (80%) who taught inter-ethnic difference in PK attributed inter-ethnic differences to genetic polymorphism. While genetic polymorphism is one source of variability in PK, the teaching of genetic polymorphism is better associated with interindividual variabilities rather than inter-ethnic differences in PK as there are no genes with PK implications specific to any one ethnic group. Nongenetic factors such as diet, weight, and environmental factors, should be highlighted as potential sources of interindividual variation in the PK of drugs.
Collapse
Affiliation(s)
- Olusola Olafuyi
- Division of Physiology, Pharmacology and NeurosciencesSchool of Life SciencesUniversity of NottinghamNottinghamUK
| | - Nikita Parekh
- Department of Pharmacology and TherapeuticsKing’s College LondonLondonUK
| | - Jacob Wright
- Centre for Bioscience EducationKing’s College LondonLondonUK
| | - Jennifer Koenig
- Division of Medical Sciences & Graduate Entry MedicineSchool of MedicineUniversity of NottinghamNottinghamUK
| |
Collapse
|
12
|
Mohamed S, Mei Fong C, Jie Ming Y, Naila Kori A, Abdul Wahab S, Mohd Ali Z. Evaluation of an Initiation Regimen of Warfarin for International Normalized Ratio Target 2.0 to 3.0. J Pharm Technol 2021; 37:286-292. [PMID: 34790965 DOI: 10.1177/87551225211034175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background: he number of patients on warfarin therapy is rising steadily. Although warfarin is beneficial, it carries a high risk of bleeding, especially if the international normalized ratio (INR) values exceed 3.0. Currently, no warfarin initiation regimens have been developed for the Asian population, especially for Malaysians. Objective: This article describes the efficacy and safety of a new initiation regimen for warfarin among warfarin-naive patients. Method: Data were retrospectively collected from the ambulatory and inpatient settings. Results: A total of 165 patients who each had a target INR of 2.0 to 3.0 were included in the study. The mean age was 57.2 years and 94 patients were male. A total of 108 patients used Regimen 1 (5 mg/5 mg/3mg) and the rest of the patients used Regimen 2 (5 mg/3 mg/3 mg). Most patients used warfarin either for atrial fibrillation (52.1%) or for venous thromboembolism (29.7%). Overall, 88 of the patients had INR values above 50% from the baseline on Day 4. Additionally, 13 patients had INR values of >3.2, which required withholding and lower dose of warfarin. The predicted weekly maintenance warfarin dose (23 ± 0.5 mg/week) was found to have correlated closely with the actual maintenance dose (22.8 ± 0.5 mg/week; r 2 = 0.75). Nearly two thirds (70.3%) of the patients achieved the target INR on Day 11. Conclusion: The warfarin initiation regimens in this study was simple, safe, and suitable to be used in both ambulatory and inpatient settings for managing warfarin therapy.
Collapse
Affiliation(s)
| | - Chan Mei Fong
- Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia
| | - Yew Jie Ming
- Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia
| | | | | | | |
Collapse
|
13
|
Alwhaibi A, Alenazi M, Alwagh F, Al-Ghayhab A, Alghadeer S, Bablghaith S, Wajid S, Al-Arifi M. Does Ramadan fasting disrupt international normalised ratio control in warfarin-treated medically stable patients? Int J Clin Pract 2021; 75:e14796. [PMID: 34482618 DOI: 10.1111/ijcp.14796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022] Open
Abstract
AIM Warfarin is commonly used in patients with thrombotic diseases. This study aimed to evaluate the impact of Ramadan fasting on warfarin efficacy by investigating international normalised ratio (INR) stability in medically stable patients. METHODS A retrospective observational study was conducted at King Khalid University Hospital during Ramadan 2016 on fasting adult patients aged above 18 years and receiving warfarin. The INR values during pre-Ramadan, Ramadan and post-Ramadan periods were collected after satisfying the inclusion criteria. Time within the therapeutic range (TTR) during the whole period was estimated using the conventional method. RESULTS In total, 101 patients were included in the study. The mean age (SD) was 55.8 ± 15.5 years, and 52.4% were females. The target INR range for 62.4% was 2-3, while 37.6% had a target INR range of 2.5-3.5. An upward trend in the proportion of patients with therapeutic INR was noticed during Ramadan (59.4%) as compared to pre- (56.4%) and post-Ramadan periods (53.5%) respectively. Additionally, the proportions of patients with supratherapeutic and sub-therapeutic INR were the highest and lowest, 23% and 24% respectively post-Ramadan as compared to other periods. Based on target INR categorisation, achieving therapeutic INR during Ramadan was more feasible with the low INR (2-3) compared to the high INR (2.5-3.5) target patients, 63.5% vs 52.6% respectively. TTR estimation revealed 62.4% and 37.6% of the patients had good and poor, respectively, anticoagulation status throughout the study period. CONCLUSION Despite the changes in mean INR and proportion of patients with therapeutic INR during Ramadan compared to other non-fasting months, our results confirmed that short-term fasting during Ramadan has no significant influence on INR stability and, consequently, therapeutic efficacy in warfarin-treated medically stable patients.
Collapse
Affiliation(s)
| | - Miteb Alenazi
- Pharmacy Department, King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia
| | - Fouzia Alwagh
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | | | - Sultan Alghadeer
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Department of Basic Sciences, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Salmeen Bablghaith
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Syed Wajid
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Al-Arifi
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
14
|
GERDAN V. Akılcı ilaç kullanımı: Varfarin. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
15
|
Debortoli G, de Araujo GS, Fortes-Lima C, Parra EJ, Suarez-Kurtz G. Identification of ancestry proportions in admixed groups across the Americas using clinical pharmacogenomic SNP panels. Sci Rep 2021; 11:1007. [PMID: 33441860 PMCID: PMC7806998 DOI: 10.1038/s41598-020-80389-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/14/2020] [Indexed: 11/09/2022] Open
Abstract
We evaluated the performance of three PGx panels to estimate biogeographical ancestry: the DMET panel, and the VIP and Preemptive PGx panels described in the literature. Our analysis indicate that the three panels capture quite well the individual variation in admixture proportions observed in recently admixed populations throughout the Americas, with the Preemptive PGx and DMET panels performing better than the VIP panel. We show that these panels provide reliable information about biogeographic ancestry and can be used to guide the implementation of PGx clinical decision-support (CDS) tools. We also report that using these panels it is possible to control for the effects of population stratification in association studies in recently admixed populations, as exemplified with a warfarin dosing GWA study in a sample from Brazil.
Collapse
Affiliation(s)
- Guilherme Debortoli
- Department of Anthropology, University of Toronto at Mississauga, Mississauga, ON, Canada
| | | | - Cesar Fortes-Lima
- Sub-Department of Human Evolution, Department of Organismal Biology, Evolutionary Biology Centre, Uppsala University, Uppsala, Sweden
| | - Esteban J Parra
- Department of Anthropology, University of Toronto at Mississauga, Mississauga, ON, Canada.
| | - Guilherme Suarez-Kurtz
- Instituto Nacional de Câncer and Rede Nacional de Farmacogenética, Rio de Janeiro, Brazil.
| |
Collapse
|
16
|
Yoon BW, Hong JY. Spontaneous intermuscular hematoma in a patient receiving ticagrelor and aspirin: A case report. Biomed Rep 2021; 14:28. [PMID: 33408862 PMCID: PMC7780748 DOI: 10.3892/br.2020.1404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/14/2020] [Indexed: 12/05/2022] Open
Abstract
Dual antiplatelet therapy is a cornerstone treatment following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Ticagrelor, a direct-acting potent P2Y12 inhibitor, is superior to clopidogrel in the acute setting of ACS: due to its faster onset and potent antiplatelet inhibition. Thus, ticagrelor is becoming widely recommended as the as the initial treatment following PCI in current guidelines. However, due to its potency, the risk of bleeding is higher. Herein, a report of an unusual case of spontaneous intermuscular hematoma is described. Furthermore, single-nucleotide polymorphisms that may be related to bleeding in ticagrelor using population-based genome-wide association studies were also identified and are discussed. As there is a concern that patients of Asian origin may have a higher risk of bleeding, physicians must be made aware of this risk when prescribing ticagrelor to individuals of Asian decent.
Collapse
Affiliation(s)
- Byung Woo Yoon
- Department of Internal Medicine, Division of Hemato-Oncology, Seoul Paik Hospital, Seoul 04551, Republic of Korea.,Inje University, College of Medicine, Busan 47392, Republic of Korea
| | - Ji Yeon Hong
- Department of Internal Medicine, Division of Cardiology, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Republic of Korea
| |
Collapse
|
17
|
Faruqui A, Pradhyumna M, Joshi S. Use and adherence to oral anticoagulants in a tertiary care hospital. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_174_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
18
|
Xu Y, Siegal DM, Anand SS. Ethnoracial variations in venous thrombosis: Implications for management, and a call to action. J Thromb Haemost 2021; 19:30-40. [PMID: 33078911 DOI: 10.1111/jth.15140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022]
Abstract
Despite decades of improvement in its diagnosis and management, venous thromboembolism (VTE) remains a significant cause of cardiovascular morbidity and mortality. Clinically relevant differences exist in the risk of symptomatic VTE among ethnoracial groups. Underlying these differences in rates of VTE are patterns of known genetic thrombophilias, which may also influence the risks of major bleeding related to vitamin K antagonists or direct oral anticoagulants. In addition, social factors, differential access to care, and disease awareness differ between ethnoracial groups, which contributes to disparities in VTE outcomes that include higher fatal events. The vast majority of participants included in clinical trials for the prevention and treatment of VTE have been White Caucasian, which limits our understanding of the differential impact of these agents in non-White ethnoracial groups. Increasing the participation in clinical trials of diverse ethnoracial groups should be a priority, especially those groups who are disproportionately affected by the burden of VTE, or possible bleeding complications when exposed to anticoagulants. Advocacy by patients, researchers, and regulatory bodies is crucial to ensure adequate enrolment of diverse ethnoracial groups in order to best inform clinical decisions to optimize VTE prevention and treatment for non-White populations.
Collapse
Affiliation(s)
- Yan Xu
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Deborah M Siegal
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
19
|
Veeregowda SH, Krishnaswamy B, Balakrishna S. Effect of Vitamin K Epoxide Reductase Complex 1 Polymorphism on Warfarin Dose Requirement among Patients in Tertiary Care Hospital. Int J Appl Basic Med Res 2020; 10:97-101. [PMID: 32566525 PMCID: PMC7289213 DOI: 10.4103/ijabmr.ijabmr_341_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/11/2019] [Accepted: 01/23/2020] [Indexed: 11/04/2022] Open
Abstract
Background Warfarin, anticoagulant is used for thromboembolic disorders. Inter-individual variation in clinical response to warfarin is due to various factors, including polymorphism of Vitamin K epoxide reductase complex 1 (VKORC1)-1639G>A. The aim of our study was to evaluate the effect of VKORC1 polymorphism on the maintenance dose of warfarin. Materials and Methods Cross-sectional study conducted by the departments of Pharmacology, Cell Biology and Molecular Genetics on patients attending cardiology clinic, receiving warfarin for at least 2 months. Genomic deoxyribonucleic acid was extracted and genotyping was done by Polymerase Chain Reaction - Restriction Fragment Length Polymorphism. The correlation between VKORC1 gene polymorphism and warfarin maintenance dose was analyzed. Results A total of 102 patients with a mean age of 47.72 ± 10.31 years, of which 58 (56.86%) were male. The frequency of VKORC1 G>A for GG, GA, and AA genotypes was 74.51%, 19.61%, and 5.88%, respectively. Variant allele AA was less frequent than the wild type. Mean weekly warfarin dose was 23.12 ± 8.08, 22.93 ± 8.21, and 15.6 ± 5.35 mg in patients with GG, GA, and AA genotypes, respectively. Patients with GG genotype required therapeutic dose compared to variant type (P = 0.001). Multiple stepwise regression model showed 26.3% variability in warfarin dose was due to VKORC1 genotype (R = 0.513, R2 = 0.263, adjusted R2 = 0.256, P = 0.0001). Conclusion VKORC1 polymorphism alone influence 26.3% variability in warfarin dose and AA genotype patients required lower dose.
Collapse
Affiliation(s)
- Sahana Hadihalli Veeregowda
- Department of Pharmacology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Bhuvana Krishnaswamy
- Department of Pharmacology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Sharath Balakrishna
- Department of Cell Biology and Molecular Genetics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| |
Collapse
|
20
|
Coleman CI, Thompson S, Ashton V, Palladino M, Bunz TJ. Rivaroxaban Versus Warfarin in African American Patients with Nonvalvular Atrial Fibrillation. J Natl Med Assoc 2020; 112:395-401. [PMID: 32493618 DOI: 10.1016/j.jnma.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Black patients are under-represented in randomized trials evaluating oral anticoagulants in non-valvular atrial fibrillation (NVAF). We sought to evaluate the effectiveness and safety of rivaroxaban versus warfarin in African Americans with NVAF. METHODS We performed an analysis using Optum® De-Identified Electronic Health Record (EHR) data from 1/1/2012-9/30/2018. We included adult African American patients with a diagnosis of NVAF who were anticoagulant-naïve during the 12-months prior to initiation of rivaroxaban or warfarin. Patients receiving rivaroxaban were 1:1 propensity score matched to warfarin patients. Our primary effectiveness and safety outcomes were the 2-year incidence rates (%/year) of stroke or systemic embolism (SSE) and major bleeding using an intention-to-treat approach. Cohorts were compared using doubly-robust Cox regression and reported as hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS We matched 4102 rivaroxaban and 4102 warfarin users with a median (interquartile range) available follow-up of 2.0 (0.9, 2.0) years. Median CHA2DS2-VASc and HASBLED scores were 3 (2, 4) and 2 (1, 3). Rivaroxaban use was associated with a lower risk of SSE (1.99 versus 2.48, HR = 0.77, 95%CI = 0.60-0.99), ischemic stroke (1.84 versus 2.37, HR = 0.76, 95%CI = 0.59-0.98) and major bleeding (4.22 versus 4.98, HR = 0.84, 95%CI = 0.70-0.99). No differences in intracranial hemorrhage or gastrointestinal bleeding were observed. Neither sensitivity analyses utilizing an on-treatment methodology nor inverse probability-of-treatment weighting showed significant differences in SSE or major bleeding between rivaroxaban and warfarin users. CONCLUSIONS Rivaroxaban appeared at least as effective and safe as warfarin when used to manage African American patients with NVAF in routine practice.
Collapse
Affiliation(s)
- Craig I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA; Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA.
| | | | - Veronica Ashton
- Real World Value and Evidence, Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | | | - Thomas J Bunz
- Department of Pharmacoepidemiology, New England Health Analytics LLC, Granby, CT, USA
| |
Collapse
|
21
|
Kim V, Wal TVD, Nishi MY, Montenegro LR, Carrilho FJ, Hoshida Y, Ono SK. Brazilian cohort and genes encoding for drug-metabolizing enzymes and drug transporters. Pharmacogenomics 2020; 21:575-586. [PMID: 32486903 DOI: 10.2217/pgs-2020-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background & aim: Genetic variability in drug absorption, distribution, metabolism and excretion (ADME) genes contributes to the high heterogeneity of drug responses. The present study investigated polymorphisms of ADME genes frequencies and compared the findings with populations from other continents, available in the 1000 Genome Project (1 KGP) and the Exome Aggregation Consortium (ExAC) databases. Methodology & results: We conducted a study of 100 patients in Brazil and a total of 2003 SNPs were evaluated by targeted next-generation sequencing in 148 genes, including Phase I enzymes (n = 50), Phase II enzymes (n = 38) and drug transporters (n = 60). Overall, the distribution of minor allele frequency (MAF) suggests that the distribution of 2003 SNPs is similar between Brazilian cohort, 1 KGP and ExAC; however, we found moderate SNP allele-frequency divergence between Brazilian cohort and both 1000 KGP and ExAC. These differences were observed in several relevant genes including CYP3A4, NAT2 and SLCO1B1. Conclusion: We concluded that the Brazilian population needs clinical assessment of drug treatment based on individual genotype rather than ethnicity.
Collapse
Affiliation(s)
- Vera Kim
- Division of Clinical Gastroenterology & Hepatology, Department of Gastroenterology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, 05403-000, Brazil.,Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Thijs van der Wal
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Miriam Yumie Nishi
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Luciana Ribeiro Montenegro
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Flair Jose Carrilho
- Division of Clinical Gastroenterology & Hepatology, Department of Gastroenterology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Yujin Hoshida
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, NY 10029, USA.,Liver Tumor Transnational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Suzane Kioko Ono
- Division of Clinical Gastroenterology & Hepatology, Department of Gastroenterology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, 05403-000, Brazil
| |
Collapse
|
22
|
Wang CA, Hsieh YC, Huang CY, Liu JC, Hsieh MH, Lin YK, Yeh JS. Comparison between ticagrelor versus clopidogrel in long term outcomes of Taiwanese diabetic subjects with acute coronary syndrome undergoing successful revascularization: From TSOC ACS-DM registry. Medicine (Baltimore) 2020; 99:e19969. [PMID: 32384446 PMCID: PMC7220397 DOI: 10.1097/md.0000000000019969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although previous clinical trials demonstrated that ticagrelor could reduce cardiovascular events and mortality versus clopidogrel in patients with acute coronary syndrome (ACS), the real-world evidence of its clinical impacts on East Asian Diabetic population has rarely been investigated.Between November 2013 and June 2015, 1534 patients were recruited into the Acute Coronary Syndrome-Diabetes Mellitus Registry of the Taiwan Society of Cardiology (TSOC ACS-DM registry). After propensity score matching, a total of 730 patients undergoing successful revascularization and discharged on ticagrelor (N = 365) or clopidogrel (N = 365) were analyzed. The primary and secondary endpoints were all-cause mortality and re-hospitalization, respectively. The all-cause death associated with ticagrelor vs clopidogrel was 3.6% vs 7.4% (adjusted hazard ratio (HR) 0.34 [0.15-0.80]; P = .0138) at 24 months. The re-hospitalization rate at 24 months was 38.9% vs 39.2% (P = .3258).For diabetic patients with ACS, ticagrelor provided better survival benefit than clopidogrel without an increase of re-hospitalization in 24 months after successful percutaneous coronary intervention. This study in real-world circumstance provided valuable complementary data to externally validate platelet inhibition and patient outcomes (PLATO) finding especially in Asian diabetic population.
Collapse
Affiliation(s)
- Cheng-An Wang
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Taipei Heart Institute
| | - Yi-Chen Hsieh
- Ph.D Program of Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University
- Ph.D Program in Biotechnology Research and Development, College of Pharmacy, Taipei Medical University
- Master Program in Applied Molecular Epidemiology, College of Public Health, Taipei Medical University
| | - Chun-Yao Huang
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Taipei Heart Institute
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei
| | - Ju-Chi Liu
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Taipei Heart Institute
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan
| | - Ming-Hsiung Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Taipei Heart Institute
| | - Yung-Kuo Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Taipei Heart Institute
| | - Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Taipei Heart Institute
| |
Collapse
|
23
|
Zhong Y, De T, Alarcon C, Park CS, Lec B, Perera MA. Discovery of novel hepatocyte eQTLs in African Americans. PLoS Genet 2020; 16:e1008662. [PMID: 32310939 PMCID: PMC7192504 DOI: 10.1371/journal.pgen.1008662] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 04/30/2020] [Accepted: 02/11/2020] [Indexed: 12/21/2022] Open
Abstract
African Americans (AAs) are disproportionately affected by metabolic diseases and adverse drug events, with limited publicly available genomic and transcriptomic data to advance the knowledge of the molecular underpinnings or genetic associations to these diseases or drug response phenotypes. To fill this gap, we obtained 60 primary hepatocyte cultures from AA liver donors for genome-wide mapping of expression quantitative trait loci (eQTL) using LAMatrix. We identified 277 eGenes and 19,770 eQTLs, of which 67 eGenes and 7,415 eQTLs are not observed in the Genotype-Tissue Expression Project (GTEx) liver eQTL analysis. Of the eGenes found in GTEx only 25 share the same lead eQTL. These AA-specific eQTLs are less correlated to GTEx eQTLs. in effect sizes and have larger Fst values compared to eQTLs found in both cohorts (overlapping eQTLs). We assessed the overlap between GWAS variants and their tagging variants with AA hepatocyte eQTLs and demonstrated that AA hepatocyte eQTLs can decrease the number of potential causal variants at GWAS loci. Additionally, we identified 75,002 exon QTLs of which 48.8% are not eQTLs in AA hepatocytes. Our analysis provides the first comprehensive characterization of AA hepatocyte eQTLs and highlights the unique discoveries that are made possible due to the increased genetic diversity within the African ancestry genome.
Collapse
Affiliation(s)
- Yizhen Zhong
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Tanima De
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Cristina Alarcon
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - C. Sehwan Park
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Bianca Lec
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Minoli A. Perera
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- * E-mail:
| |
Collapse
|
24
|
Zhang H, De T, Zhong Y, Perera MA. The Advantages and Challenges of Diversity in Pharmacogenomics: Can Minority Populations Bring Us Closer to Implementation? Clin Pharmacol Ther 2020; 106:338-349. [PMID: 31038731 DOI: 10.1002/cpt.1491] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/18/2019] [Indexed: 01/01/2023]
Abstract
Health disparities exist among minorities in the United States, with differences seen in disease prevalence, mortality, and responses to medications. These differences are multifactorial with genetic variation explaining a portion of this variability. Pharmacogenomics aims to find the effect of genetic variations on drug response, with the goal of optimizing drug therapy and development. Although genome-wide association studies have been useful in unbiasedly surveying the genome for genetic drivers of clinically relevant phenotypes, most of these studies have been conducted in mainly participants of European and Asian descent, contributing to a growing health disparity in precision medicine. Diversity is important to pharmacogenomic studies, and there may be real advantages to the use of these complex genomes in pharmacogenomics. In this review we will outline some of the advantages and confounders of pharmacogenomics in minorities, describe the role of genetic variation in pharmacologic pathways, and highlight a number of population-specific findings.
Collapse
Affiliation(s)
- Honghong Zhang
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tanima De
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Yizhen Zhong
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
25
|
Gibson CM, Yuet WC. Racial and Ethnic Differences in Response to Anticoagulation: A Review of the Literature. J Pharm Pract 2019; 34:685-693. [PMID: 31875763 DOI: 10.1177/0897190019894142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Anticoagulants are among the most frequently prescribed medications in the United States. Racial and ethnic disparities in incidence and outcomes of thrombotic disorders are well-documented, but differences in response to anticoagulation are incompletely understood. OBJECTIVE The objective of this review is to describe the impact of race and ethnicity on surrogate and clinical end points related to anticoagulation and discuss racial or ethnic considerations for prescribing anticoagulants. METHODS A PubMed and MEDLINE search of clinical trials published between 1950 and May 2018 was conducted using search terms related to anticoagulation, specific anticoagulant drugs, race, and ethnicity. References of identified studies were also reviewed. English-language human studies on safety or efficacy of anticoagulants reporting data for different races or ethnicities were eligible for inclusion. RESULTS Seventeen relevant studies were identified. The majority of major trials reviewed for inclusion either did not include representative populations or did not report on the racial breakdown of participants. Racial differences in pharmacokinetics, dosing requirements, drug response, and/or safety end points were identified for unfractionated heparin, enoxaparin, argatroban, warfarin, rivaroxaban, and edoxaban. CONCLUSIONS Race appears to influence drug concentrations, dosing, or safety for some but not all direct oral anticoagulants. This information should be considered when selecting anticoagulant therapy for nonwhite individuals.
Collapse
Affiliation(s)
- Caitlin M Gibson
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Wei C Yuet
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| |
Collapse
|
26
|
Towards precision medicine: interrogating the human genome to identify drug pathways associated with potentially functional, population-differentiated polymorphisms. THE PHARMACOGENOMICS JOURNAL 2019; 19:516-527. [PMID: 31578463 PMCID: PMC6867962 DOI: 10.1038/s41397-019-0096-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/10/2019] [Accepted: 09/18/2019] [Indexed: 12/24/2022]
Abstract
Drug response variations amongst different individuals/populations are influenced by several factors including allele frequency differences of single nucleotide polymorphisms (SNPs) that functionally affect drug-response genes. Here, we aim to identify drugs that potentially exhibit population differences in response using SNP data mining and analytics. Ninety-one pairwise-comparisons of >22,000,000 SNPs from the 1000 Genomes Project, across 14 different populations, were performed to identify ‘population-differentiated’ SNPs (pdSNPs). Potentially-functional pdSNPs (pf-pdSNPs) were then selected, mapped into genes, and integrated with drug–gene databases to identify ‘population-differentiated’ drugs enriched with genes carrying pf-pdSNPs. 1191 clinically-approved drugs were found to be significantly enriched (Z > 2.58) with genes carrying SNPs that were differentiated in one or more population-pair comparisons. Thirteen drugs were found to be enriched with such differentiated genes across all 91 population-pairs. Notably, 82% of drugs, which were previously reported in the literature to exhibit population differences in response were also found by this method to contain a significant enrichment of population specific differentiated SNPs. Furthermore, drugs with genetic testing labels, or those suspected to cause adverse reactions, contained a significantly larger number (P < 0.01) of population-pairs with enriched pf-pdSNPs compared with those without these labels. This pioneering effort at harnessing big-data pharmacogenomics to identify ‘population differentiated’ drugs could help to facilitate data-driven decision-making for a more personalized medicine.
Collapse
|
27
|
Maintenance dose of warfarin beyond time in therapeutic range for preventing vascular events. J Neurol Sci 2019; 398:69-74. [PMID: 30684767 DOI: 10.1016/j.jns.2019.01.031] [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: 11/11/2018] [Revised: 12/29/2018] [Accepted: 01/17/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The quality of anticoagulation is closely associated with efficacy and safety in warfarin users. Although genetic polymorphisms have been related to warfarin dosages and vascular events(VE), genetic evaluations have not been recommended for all warfarin users. The aim is to evaluate the significance of the maintenance dose of warfarin (MDW) on VE, considering the time in therapeutic range (TTR). METHODS This retrospective study analyzed the data of patients who received warfarin for any reasons. A total of 11,835 patients with warfarin were divided into quartiles by MDW. We assessed TTR using the Rosendaal method and VE. RESULTS VE occurred in 9.1% of the warfarin users. The mean TTR level was 34.0 ± 25.7%, and the MDW was 3.38 ± 1.06 mg per day. Patients with VE were more likely to have a lower MDW and lower TTR levels. In moderate- or well-controlled TTR status, a lower MDW was significantly related to under-controlled anticoagulation and associated with higher risks of VE. Lower MDW had a higher risk of stroke or arterial/venous thromboembolism (Q1: OR, 1.57; 95% CI 1.25 to 1.96; Q2: OR, 1.40; 95% CI 1.12 to 1.75; Q3: OR, 1.35; 95% CI 1.08 to 1.68). CONCLUSIONS We suggest that patients with very low MDW might be at risk when using warfarin. Therefore, we propose that patients with a very low MDW might be alternatively considered for novel oral anticoagulants rather than warfarin.
Collapse
|
28
|
Effects of fasting on warfarin sensitivity index in patients undergoing cardiovascular surgery. Eur J Clin Pharmacol 2018; 75:561-568. [DOI: 10.1007/s00228-018-2592-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/30/2018] [Indexed: 12/27/2022]
|
29
|
De T, Alarcon C, Hernandez W, Liko I, Cavallari LH, Duarte JD, Perera MA. Association of Genetic Variants With Warfarin-Associated Bleeding Among Patients of African Descent. JAMA 2018; 320:1670-1677. [PMID: 30357299 PMCID: PMC6233811 DOI: 10.1001/jama.2018.14955] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Major warfarin-related bleeding occurs more frequently in African Americans than in other populations. Identification of potential genetic factors related to this adverse event may help identify at-risk patients. OBJECTIVE To identify genetic factors associated with warfarin-related bleeding in patients of African descent at an international normalized ratio (INR) of less than 4. DESIGN, SETTING, AND PARTICIPANTS A case-control genome-wide association study involving patients of African descent taking warfarin was conducted in a discovery cohort (University of Chicago [2009-2011] and the University of Illinois at Chicago [2002-2011]), and associations were confirmed in a replication cohort (University of Chicago [2015-2016]). Potential population stratification was examined in the discovery cohort by principal component analysis. Odds ratios (ORs) and 95% CIs were computed for bleeding risk by logistic regression analysis. Summary statistics from the discovery and the replication cohorts were analyzed with a fixed effects meta-analysis. The potential influence of single-nucleotide polymorphisms (SNPs) on gene expression was studied by luciferase expression assays. EXPOSURES Single-nucleotide polymorphisms associated with warfarin-related bleeding. MAIN OUTCOMES AND MEASURES Major bleeding-defined as bleeding requiring hospitalization, causing a decrease in hemoglobin level of more than 2 g/dL, requiring blood transfusion, or any combination of the 3-while taking warfarin at an INR of less than 4. RESULTS The discovery cohort consisted of 31 cases (mean age, 60.1 years [SD, 14.9 years], 26 women [83.9%]) and 184 warfarin-treated controls (mean age, 57.1 years [SD, 15.7 years]) with no documented bleeding. The replication cohort consisted of 40 cases (mean age, 55.6 years [SD, 17.3 years], 27 women [67.5%]), and 148 warfarin-treated controls (mean age, 55.4 years [SD, 17.1 years]; 98 women [66.2%]) with no documented bleeding. In the discovery cohort, 4 SNPs in linkage disequilibrium on chromosome 6 (rs115112393, rs16871327, rs78132896, and rs114504854) were associated with warfarin-related bleeding but did not reach genome-wide significance. The SNP rs78132896 occurred in 11 cases (35.5%) and 9 controls (4.9%) in the discovery cohort (OR, 8.31; 95% CI, 3.2-21.5; P < 6.21 × 10-8), and the association was confirmed in the replication cohort (the SNP was present in 14 cases [35.0%] and 7 controls [4.8%]; OR, 8.24; 95% CI, 3.1-25.3, P = 5.64 × 10-5). Genome-wide significance of this SNP was achieved when the cohorts were combined via meta-analysis (OR, 8.27; 95% CI, 4.18-16.38; P = 2.05 × 10-11). These SNPs are found only in people of African descent. In vitro luciferase expression assays demonstrated that rs16871327 (enhancer SNP) and rs78132896 (promoter SNP) risk alleles together increased EPHA7 gene (Entrez Gene 2045) transcription by a mean of 14.95 (SD, 1.7) compared with wild-type alleles (mean, 9.56 [SD, 0.84]; difference, 5.39; 95% CI, 4.1-6.6; P < .001). CONCLUSIONS AND RELEVANCE In this preliminary study involving patients of African descent taking warfarin, 4 single-nucleotide polymorphisms in linkage disequilibrium on chromosome 6 were associated with an increased risk of major bleeding at INR of less than 4. Validation of these findings in an independent prospective cohort is required.
Collapse
Affiliation(s)
- Tanima De
- Northwestern University, Department of Pharmacology, Chicago, Illinois
| | - Cristina Alarcon
- Northwestern University, Department of Pharmacology, Chicago, Illinois
| | - Wenndy Hernandez
- University of Chicago, Section of Genetic Medicine, Department of Medicine, Chicago, Illinois
| | - Ina Liko
- University of Illinois College of Pharmacy, Department of Pharmacy Practice, Chicago
| | - Larisa H. Cavallari
- University of Florida, College of Pharmacy, Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, Gainesville
| | - Julio D. Duarte
- University of Florida, College of Pharmacy, Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, Gainesville
| | - Minoli A. Perera
- Northwestern University, Department of Pharmacology, Chicago, Illinois
| |
Collapse
|
30
|
Galvez JM, Restrepo CM, Contreras NC, Alvarado C, Calderón-Ospina CA, Peña N, Cifuentes RA, Duarte D, Laissue P, Fonseca DJ. Creating and validating a warfarin pharmacogenetic dosing algorithm for Colombian patients. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:169-178. [PMID: 30410385 PMCID: PMC6198877 DOI: 10.2147/pgpm.s170515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose Warfarin is an oral anticoagulant associated with adverse reaction to drugs due to wide inter- and intra-individual dosage variability. Warfarin dosage has been related to non-genetic and genetic factors. CYP2C9 and VKORC1 gene polymorphisms affect warfarin metabolism and dosage. Due to the central role of populations’ ethnical and genetic origin on warfarin dosage variability, novel algorithms for Latin American subgroups are necessary to establish safe anticoagulation therapy. Patients and methods We genotyped CYP2C9*2 (c.430C > T), CYP2C9*3 (c.1075A > C), CYP4F2 (c.1297G > A), and VKORC1 (−1639 G > A) polymorphisms in 152 Colombian patients who received warfarin. We evaluated the impact on the variability of patients’ warfarin dose requirements. Multiple linear regression analysis, using genetic and non-genetic variables, was used for creating an algorithm for optimal warfarin maintenance dose. Results Median weekly prescribed warfarin dosage was significantly lower in patients having the VKORC1-1639 AA genotype and poor CYP2C9*2/*2,*2/*3 metabolizers than their wild-type counterparts. We found a 2.3-fold increase in mean dose for normal sensitivity patients (wild-type VKORC1/CYP2C9 genotypes) compared to the other groups (moderate and high sensitivity); 31.5% of the patients in our study group had warfarin sensitivity-related genotypes. The estimated regression equation accounted for 44.4% of overall variability in regard to warfarin maintenance dose. The algorithm was validated, giving 45.9% correlation (R2=0.459). Conclusion Our results describe and validate the first algorithm for predicting warfarin maintenance in a Colombian mestizo population and have contributed toward the understanding of pharmacogenetics in a Latin American population subgroup.
Collapse
Affiliation(s)
- Jubby Marcela Galvez
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Carlos Martin Restrepo
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Nora Constanza Contreras
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Clara Alvarado
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Carlos-Alberto Calderón-Ospina
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Nidia Peña
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Ricardo A Cifuentes
- Area of Basic Sciences, College of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Daniela Duarte
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Paul Laissue
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Dora Janeth Fonseca
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| |
Collapse
|
31
|
De T, Park CS, Perera MA. Cardiovascular Pharmacogenomics: Does It Matter If You're Black or White? Annu Rev Pharmacol Toxicol 2018; 59:577-603. [PMID: 30296897 DOI: 10.1146/annurev-pharmtox-010818-021154] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Race and ancestry have long been associated with differential risk and outcomes to disease as well as responses to medications. These differences in drug response are multifactorial with some portion associated with genomic variation. The field of pharmacogenomics aims to predict drug response in patients prior to medication administration and to uncover the biological underpinnings of drug response. The field of human genetics has long recognized that genetic variation differs in frequency between ancestral populations, with some single nucleotide polymorphisms found solely in one population. Thus far, most pharmacogenomic studies have focused on individuals of European and East Asian ancestry, resulting in a substantial disparity in the clinical utility of genetic prediction for drug response in US minority populations. In this review, we discuss the genetic factors that underlie variability to drug response and known pharmacogenomic associations and how these differ between populations, with an emphasis on the current knowledge in cardiovascular pharmacogenomics.
Collapse
Affiliation(s)
- Tanima De
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - C Sehwan Park
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - Minoli A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| |
Collapse
|
32
|
Ferdinand KC, Igari M. The role of racial/ethnic factors in global clinical trials. Expert Rev Clin Pharmacol 2018; 11:829-832. [PMID: 30099916 DOI: 10.1080/17512433.2018.1510311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Keith C Ferdinand
- a Tulane School of Medicine , Tulane Heart and Vascular Institute , New Orleans , LA , USA
| | - Miyako Igari
- a Tulane School of Medicine , Tulane Heart and Vascular Institute , New Orleans , LA , USA
| |
Collapse
|
33
|
Rad F, Hamidpour M, Dorgalaleh A, Poopak B. The Effect of Demographic Factors and VKORC1 1639 G>A Genotypes on Estimated Warfarin Maintenance Dose in Iranian Patients Under Warfarin Therapy. Indian J Hematol Blood Transfus 2018; 35:167-171. [PMID: 30828166 DOI: 10.1007/s12288-018-0987-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 07/06/2018] [Indexed: 12/12/2022] Open
Abstract
Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors including factor (F) II, FVII, FIX and FX. Different factors can change the effect of this anticoagulant in clinic. Therefore we assessed impact of VKORC1 -1639 G>A polymorphism and demographic factors on required maintenance dose in Iranian patients under warfarin therapy. The study population included 95 patients with a mean age of 61.3 ± 12.6 years. Target INR range of 2-3 was considered for these patients. The frequency of VKORC1 -1639 G>A polymorphism was assessed by polymerase chain reaction-restriction length polymorphism (PCR-RFLP). Finally the obtain data were analyzed by SPSS software. Our study revealed that 30.5%, 49.5%, and 20% of the patients had VKORC1 (G/G), (G/A), and (A/A) genotypes, respectively. Carriers of VKORC1 G/G genotype required a higher warfarin dose as compared to A/A carriers (4.48 ± 1.32 and 2.7 ± 1.16 mg/day, respectively; P < 0.01). In addition, patients with higher age required lower warfarin therapeutic dose (r = - 0.3, P < 0.01). It seems that -1639 G>A polymorphism and demographic variables had significant effects on warfarin maintenance dose in Iranian patients under warfarin therapy.
Collapse
Affiliation(s)
- Fariba Rad
- 1Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Mohsen Hamidpour
- 2Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Akbar Dorgalaleh
- 3Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran.,Iranian Comprehensive Hemophilia Center, Tehran, Iran
| | - Behzad Poopak
- 5School of Paramedicine, Tehran Medical Branch of Islamic Azad University, P.O. Box 19395-1495, Tehran, Iran
| |
Collapse
|
34
|
Chan YH, See LC, Tu HT, Yeh YH, Chang SH, Wu LS, Lee HF, Wang CL, Kuo CF, Kuo CT. Efficacy and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Asians With Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2018; 7:JAHA.117.008150. [PMID: 29622587 PMCID: PMC6015442 DOI: 10.1161/jaha.117.008150] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin among Asians with nonvalvular atrial fibrillation remains unclear. Methods and Results In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, there were 5843, 20 079, 27 777, and 19 375 nonvalvular atrial fibrillation patients taking apixaban, dabigatran, rivaroxaban and warfarin, respectively, from June 1, 2012 to December 31, 2016. Propensity‐score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any efficacy or safety outcome or the end date of study. Hazard ratios (95% confidence intervals) comparing apixaban, dabigatran, and rivaroxaban with warfarin were: ischemic stroke/systemic embolism (IS/SE), 0.55 (0.43–0.69), 0.82 (0.68–0.98), and 0.81 (0.67–0.97); major bleeding, 0.41 (0.31–0.53), 0.65 (0.53–0.80), and 0.58 (0.46–0.72); and all‐cause mortality, 0.58 (0.51–0.66), 0.61 (0.54–0.68), and 0.57 (0.51–0.65). A total of 3623 (62%), 17 760 (88%), and 26 000 (94%) patients were taking low‐dose apixaban (2.5 mg twice daily), dabigatran (110 mg twice daily), and rivaroxaban (10–15 mg once daily), respectively. Similar to all‐dose NOACs, all low‐dose NOACs had lower risk of IS/SE, major bleeding, and mortality when compared with warfarin. In contrast to other standard‐dose NOACs, apixaban was associated with lower risks of IS/SE (0.45 [0.31–0.65]), major bleeding (0.29 [0.18–0.46]), and mortality (0.23 [0.17–0.31]) than warfarin. Conclusions All NOACs were associated with lower risk of IS/SE, major bleeding, and mortality compared with warfarin in the largest real‐world practice among Asians with nonvalvular atrial fibrillation. All low‐dose NOACs had lower risk of IS/SE, major bleeding, and mortality when compared with warfarin. Standard‐dose apixaban caused a lower risk of IS/SE, major bleeding, and mortality compared with warfarin.
Collapse
Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Li Wang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan .,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
35
|
Bernaitis N, Badrick T, Anoopkumar-Dukie S. Dedicated warfarin care programme results in superior warfarin control in Queensland, Australia. Int J Clin Pract 2018; 72:e13051. [PMID: 29316055 DOI: 10.1111/ijcp.13051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/06/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Warfarin is used to prevent stroke in patients with atrial fibrillation (AF). Ongoing monitoring of International normalised ratio (INR) and time in therapeutic range (TTR) commonly used to assess the quality of warfarin management are required. Anticoagulant clinics have demonstrated improved TTRs, particularly in countries with poorer control in primary care settings. Reported TTR in Australia has been relatively high; so, it is unknown if benefit would be seen from dedicated warfarin clinics in Australia. The aim of this study was to compare the level of warfarin control in patients managed by their general practitioner (GP) and a warfarin care programme (WCP) by Sullivan Nicolaides Pathology. METHOD Retrospective data were collected for AF patients enrolled in the warfarin care programme at WCP, and included patients with INR tests available while managed by their GP. INR tests were used to calculate TTR and frequency of testing for the time managed by GP and WCP, with mean data used for analysis and comparison. RESULTS The eligible 200 warfarin patients had a TTR of 69% with GP management and 82% with WCP management (<.0001). Significant differences were also found between GP and WCP management in the percentage of tests in range, total number of tests and frequency of testing. WCP had a reduced time to repeat test at extremes of INR results. CONCLUSION Australian warfarin control was good when managed by either GP or WCP, but WCP management increased TTR by 13%. Dedicated warfarin programmes can improve warfarin control and optimise therapy for patients.
Collapse
Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute and Quality Use of Medicines Network, Griffith University, Queensland, Australia
- School of Pharmacy and Pharmacology, Griffith University, Queensland, Australia
| | - Tony Badrick
- The Royal College of Pathologists of Australasia (RCPA) Quality Assurance Programs, New South Wales, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute and Quality Use of Medicines Network, Griffith University, Queensland, Australia
- School of Pharmacy and Pharmacology, Griffith University, Queensland, Australia
| |
Collapse
|
36
|
Víquez Beita AK, Whayne TF. Higher Risk of Bleeding in Asians Presenting With ST Elevation Myocardial Infarction (STEMI). Angiology 2017; 69:461-463. [DOI: 10.1177/0003319717731961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Thomas F. Whayne
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
37
|
Kaye JB, Schultz LE, Steiner HE, Kittles RA, Cavallari LH, Karnes JH. Warfarin Pharmacogenomics in Diverse Populations. Pharmacotherapy 2017; 37:1150-1163. [PMID: 28672100 DOI: 10.1002/phar.1982] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Genotype-guided warfarin dosing algorithms are a rational approach to optimize warfarin dosing and potentially reduce adverse drug events. Diverse populations, such as African Americans and Latinos, have greater variability in warfarin dose requirements and are at greater risk for experiencing warfarin-related adverse events compared with individuals of European ancestry. Although these data suggest that patients of diverse populations may benefit from improved warfarin dose estimation, the vast majority of literature on genotype-guided warfarin dosing, including data from prospective randomized trials, is in populations of European ancestry. Despite differing frequencies of variants by race/ethnicity, most evidence in diverse populations evaluates variants that are most common in populations of European ancestry. Algorithms that do not include variants important across race/ethnic groups are unlikely to benefit diverse populations. In some race/ethnic groups, development of race-specific or admixture-based algorithms may facilitate improved genotype-guided warfarin dosing algorithms above and beyond that seen in individuals of European ancestry. These observations should be considered in the interpretation of literature evaluating the clinical utility of genotype-guided warfarin dosing. Careful consideration of race/ethnicity and additional evidence focused on improving warfarin dosing algorithms across race/ethnic groups will be necessary for successful clinical implementation of warfarin pharmacogenomics. The evidence for warfarin pharmacogenomics has a broad significance for pharmacogenomic testing, emphasizing the consideration of race/ethnicity in discovery of gene-drug pairs and development of clinical recommendations for pharmacogenetic testing.
Collapse
Affiliation(s)
- Justin B Kaye
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Lauren E Schultz
- Department of Pharmacology and Toxicology, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Rick A Kittles
- Department of Public Health, University of Arizona College of Medicine, Tucson, Arizona.,Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona.,Center for Applied Genetics and Genomic Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, Florida
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona.,Center for Applied Genetics and Genomic Medicine, University of Arizona College of Medicine, Tucson, Arizona.,Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona
| |
Collapse
|
38
|
Bernaitis N, Ching CK, Teo SC, Chen L, Badrick T, Davey AK, Crilly J, Anoopkumar-Dukie S. Factors influencing warfarin control in Australia and Singapore. Thromb Res 2017; 157:120-125. [PMID: 28738273 DOI: 10.1016/j.thromres.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 06/22/2017] [Accepted: 07/10/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Warfarin is widely used for patients with non-valvular atrial fibrillation (NVAF). Variations in warfarin control, as measured by time in therapeutic range (TTR), have been reported across different regions and ethnicities, particularly between Western and Asian countries. However, there is limited data on comparative factors influencing warfarin control in Caucasian and Asian patients. Therefore, the aim of this study was to determine warfarin control and potential factors influencing this in patients with NVAF in Australia and Singapore. METHODS Retrospective data was collected for patients receiving warfarin for January to June 2014 in Australia and Singapore. TTR was calculated for individuals with mean patient TTR used for analysis. Possible influential factors on TTR were analysed including age, gender, concurrent co-morbidities, and concurrent medication. RESULTS The mean TTR was significantly higher in Australia (82%) than Singapore (58%). At both sites, chronic kidney disease significantly lowered this TTR. Further factors influencing control were anaemia and age<60years in Australia, and vascular disease, CHA2DS2-VASc score of 6, and concurrent platelet inhibitor therapy in Singapore. DISCUSSION Warfarin control was significantly higher in Australia compared to Singapore, however chronic kidney disease reduced control at both sites. The different levels of control in these two countries, together with patient factors further reducing control may impact on anticoagulant choice in these countries with better outcomes from warfarin in Australia compared to Singapore.
Collapse
Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Chi Keong Ching
- Cardiology Department, National Heart Centre Singapore, Singapore
| | - Siew Chong Teo
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Liping Chen
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Tony Badrick
- RCPA Quality Assurance Programs, New South Wales, Australia
| | - Andrew K Davey
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Julia Crilly
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; Department of Emergency Medicine Gold Coast Health, Queensland, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia.
| |
Collapse
|
39
|
Claudio-Campos K, Labastida A, Ramos A, Gaedigk A, Renta-Torres J, Padilla D, Rivera-Miranda G, Scott SA, Ruaño G, Cadilla CL, Duconge-Soler J. Warfarin Anticoagulation Therapy in Caribbean Hispanics of Puerto Rico: A Candidate Gene Association Study. Front Pharmacol 2017; 8:347. [PMID: 28638342 PMCID: PMC5461284 DOI: 10.3389/fphar.2017.00347] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Existing algorithms account for ~50% of observed variance in warfarin dose requirements after including common polymorphisms. However, they do not perform as well in populations other than Caucasians, in part because some ethno-specific genetic variants are overlooked. The objective of the present study was to identify genetic polymorphisms that can explain variability in warfarin dose requirements among Caribbean Hispanics of Puerto Rico. Next-Generation Sequencing of candidate genes CYP2C9 and VKORC1 and genotyping by DMET® Plus Assay of cardiovascular patients were performed. We also aimed at characterizing the genomic structure and admixture pattern of this study cohort. Our study used the Extreme Discordant Phenotype approach to perform a case-control association analysis. The CYP2C9 variant rs2860905, which was found in all the major haplotypes occurring in the Puerto Rican population, showed stronger association with warfarin sensitivity (<4 mg/day) than common variants CYP2C9*2 and CYP2C9*3. Although, CYP2C9*2 and CYP2C9*3 are separately contained within two of the haplotypes, 10 subjects with the sensitive phenotype were carriers of only the CYP2C9 rs2860905 variant. Other polymorphisms in CES2 and ABCB1 were found to be associated with warfarin resistance. Incorporation of rs2860905 in a regression model (R2 = 0.63, MSE = 0.37) that also includes additional genetics (i.e., VKORC1-1639 G>A; CYP2C9 rs1856908; ABCB1 c.IVS9-44A>G/ rs10276036; CES2 c.269-965A>G/ rs4783745) and non-genetic factors (i.e., hypertension, diabetes and age) showed better prediction of warfarin dose requirements than CYP2C9*2 and CYP2C9*3 combined (partial R2 = 0.132 vs. 0.023 and 0.007, respectively, p < 0.001). The genetic background of Puerto Ricans in the study cohort showed a tri-hybrid admixture pattern, with a slightly higher than expected contribution of Native American ancestry (25%). The genomic diversity of Puerto Ricans is highlighted by the presence of four different major haplotype blocks in the CYP2C9 locus. Although, our findings need further replication, this study contributes to the field by identifying novel genetic variants that increase predictability of stable warfarin dosing among Caribbean Hispanics.
Collapse
Affiliation(s)
- Karla Claudio-Campos
- Department of Pharmacology and Toxicology, School of Medicine, University of Puerto RicoSan Juan, PR, United States
| | - Aurora Labastida
- Independent Researcher, Primera Cerrada de Camino al Amalillo 4Mexico City, Mexico
| | - Alga Ramos
- Miami VA Healthcare System, Health System Administration Pharmacy, Clinical ServicesMiami, FL, United States
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas CityKansas City, MO, United States
| | - Jessicca Renta-Torres
- Department of Biochemistry, School of Medicine, University of Puerto RicoSan Juan, PR, United States
| | - Dariana Padilla
- Department of Biology, University of Puerto Rico at Rio PiedrasSan Juan, PR, United States
| | - Giselle Rivera-Miranda
- Veterans Affairs Caribbean Healthcare Systems, Pharmacy ServiceSan Juan, PR, United States
| | - Stuart A. Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount SinaiNew York, NY, United States
- Icahn School of Medicine at Mount Sinai, The Charles Bronfman Institute for Personalized MedicineNew York, NY, United States
| | | | - Carmen L. Cadilla
- Department of Biochemistry, School of Medicine, University of Puerto RicoSan Juan, PR, United States
| | - Jorge Duconge-Soler
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Puerto RicoSan Juan, PR, United States
| |
Collapse
|
40
|
Disease burden and the role of pharmacogenomics in African populations. GLOBAL HEALTH EPIDEMIOLOGY AND GENOMICS 2017; 2:e1. [PMID: 29868213 PMCID: PMC5870420 DOI: 10.1017/gheg.2016.21] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/15/2022]
Abstract
Background The burden of communicable and non-communicable diseases in Sub-Saharan Africa poses a challenge in achieving quality healthcare. Although therapeutic drugs have generally improved health, their efficacy differs from individual to individual. Variability in treatment response is mainly because of genetic variants that affect the pharmacokinetics and pharmacodynamics of drugs. Method The intersection of disease burden and therapeutic intervention is reviewed, and the status of pharmacogenomics knowledge in African populations is explored. Results The most commonly studied variants with pharmacogenomics relevance are discussed, especially in genes coding for enzymes that affect the response to drugs used for HIV, malaria, sickle cell disease and cardiovascular diseases. Conclusions The genetically diverse African population is likely to benefit from a pharmacogenomics-based healthcare approach, especially with respect to reduction of drug side effects, and separation of responders and non-responders leading to optimized drug choices and doses for each patient.
Collapse
|
41
|
Prediction of biogeographical ancestry from genotype: a comparison of classifiers. Int J Legal Med 2016; 131:901-912. [DOI: 10.1007/s00414-016-1504-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/21/2016] [Indexed: 12/19/2022]
|
42
|
Abstract
We aim to develop warfarin dosing algorithm for African-Americans. We explored demographic, clinical, and genetic data from a previously collected cohort of 163 African-American patients with a stable warfarin dose. We explored 2 approaches to develop the algorithm: multiple linear regression and artificial neural network (ANN). The clinical significance of the 2 dosing algorithms was evaluated by calculating the percentage of patients whose predicted dose of warfarin was within 20% of the actual dose. Linear regression model and ANN model predicted the ideal dose in 52% and 48% of the patients, respectively. The mean absolute error using linear regression model was estimated to be 10.8 mg compared with 10.9 mg using ANN. Linear regression and ANN models identified several predictors of warfarin dose including age, weight, CYP2C9 genotype *1/*1, VKORC1 genotype, rs12777823 genotype, rs2108622 genotype, congestive heart failure, and amiodarone use. In conclusion, we developed a warfarin dosing algorithm for African-Americans. The proposed dosing algorithm has the potential to recommend warfarin doses that are close to the appropriate doses. The use of more sophisticated ANN approach did not result in improved predictive performance of the dosing algorithm except for patients of a dose of ≥49 mg/wk.
Collapse
|
43
|
Bernaitis N, Ching CK, Chen L, Hon JS, Teo SC, Davey AK, Anoopkumar-Dukie S. The Sex, Age, Medical History, Treatment, Tobacco Use, Race Risk (SAMe TT 2R 2) Score Predicts Warfarin Control in a Singaporean Population. J Stroke Cerebrovasc Dis 2016; 26:64-69. [PMID: 27671097 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/14/2016] [Accepted: 08/18/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Warfarin reduces stroke risk in atrial fibrillation (AF) patients but requires ongoing monitoring. Time in therapeutic range (TTR) is used as a measure of warfarin control, with a TTR less than 60% associated with adverse patient outcomes. The Sex, Age, Medical history, Treatment, Tobacco use, Race (SAMe-TT2R2) score has been identified as a model able to predict warfarin control, but this has been tested in mainly Caucasian populations. Therefore, the aim of this study was to determine the ability of the SAMe-TT2R2 score to predict warfarin control in a Singaporean population consisting of Chinese, Malay, and Indian race. METHODS Retrospective data were collected from the National Heart Centre Singapore for AF patients receiving warfarin between January and June 2014. The TTR and the SAMe-TT2R2 score were calculated for each patient. RESULTS The 1137 non-valvular AF patients had a mean TTR of 58.0 ± 34.3% and a median SAMe-TT2R2 score of 3. The categorized SAMe-TT2R2 scores (2 versus >2) showed a significant reduction in mean TTR for the entire population (63.2% versus 55.8%, P = .0004) and also when categorized according to race for Chinese (62.7% versus 56.9%, P = .0075) and Malay (68.4% versus 50.6%, P = .0131) populations. CONCLUSION The SAMe-TT2R2 tool is effective in predicting warfarin control in a Singaporean population as patients with a score greater than 2 had poor control. The minimum score for non-Caucasian patients is 2; thus, in these patients, the presence of any additional risk factors identified in the SAMe-TT2R2 tool categorizes them as unlikely to achieve adequate warfarin control and possible candidates for alternative anticoagulants.
Collapse
Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Chi Keong Ching
- Cardiology Department, National Heart Centre Singapore, Singapore
| | - Liping Chen
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Jin Shing Hon
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Siew Chong Teo
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Andrew K Davey
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia.
| |
Collapse
|
44
|
Abstract
Half of all patients with acute venous thromboembolism are aged over 70 years; they then face the added hazard of an age-related increase in the incidence of major bleeding. This makes it even more important to weigh the balance of benefit and risk when considering anticoagulant treatment and treatment duration. Traditional treatment with a heparin (usually low molecular weight) followed by a vitamin K antagonist such as warfarin is effective but is often complicated, especially in the elderly. The direct-acting oral anticoagulants (DOACs), i.e. the thrombin inhibitor dabigatran and the factor Xa inhibitors rivaroxaban, apixaban and edoxaban, are given in fixed doses, do not need laboratory monitoring, have fewer drug-drug interactions and are therefore much easier to take. Randomised trials, their meta-analyses and 'real-world' data indicate the DOACs are no less effective than warfarin (are non-inferior) and probably cause less major bleeding (especially intracranial). It seems the relative safety of DOACs extends to age above 65 or 70 years, although bleeding becomes more likely regardless of the chosen anticoagulant. Renal impairment, comorbidities (especially cancer) and interventions are special hazards. Ways to minimise bleeding include patient selection and follow-up, education about venous thromboembolism, anticoagulants, drug interactions, regular checks on adherence and avoiding needlessly prolonged treatment. The relatively short circulating half-lives of DOACs mean that time, local measures and supportive care are the main response to major bleeding. They also simplify the management of invasive interventions. An antidote for dabigatran, idarucizumab, was recently approved by regulators, and a general antidote for factor Xa inhibitors is in advanced development.
Collapse
Affiliation(s)
- Jir Ping Boey
- Department of Haematology, SA Pathology, Flinders Medical Centre, Flinders Dr, Bedford Park, SA, 5042, Australia
| | - Alexander Gallus
- Department of Haematology, SA Pathology, Flinders Medical Centre, Flinders Dr, Bedford Park, SA, 5042, Australia.
| |
Collapse
|
45
|
Yan X, Yang F, Zhou H, Zhang H, Liu J, Ma K, Li Y, Zhu J, Ding J. Effects of VKORC1 Genetic Polymorphisms on Warfarin Maintenance Dose Requirement in a Chinese Han Population. Med Sci Monit 2015; 21:3577-84. [PMID: 26583785 PMCID: PMC4657763 DOI: 10.12659/msm.894414] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background VKORC1 is reported to be capable of treating several diseases with thrombotic risk, such as cardiac valve replacement. Some single-nucleotide polymorphisms (SNPs) in VKORC1 are documented to be associated with clinical differences in warfarin maintenance dose. This study explored the correlations of VKORC1–1639 G/A, 1173 C/T and 497 T/G genetic polymorphisms with warfarin maintenance dose requirement in patients undergoing cardiac valve replacement. Material/Methods A total of 298 patients undergoing cardiac valve replacement were recruited. During follow-up, clinical data were recorded. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was applied to detect VKORC1–1639 G/A, 1173 C/T and 497 T/G polymorphisms, and genotypes were analyzed. Results Correlations between warfarin maintenance dose and baseline characteristics revealed statistical significances of age, gender and operation methods with warfarin maintenance dose (all P<0.05). Warfarin maintenance dose in VKORC1–1639 G/A AG + GG carriers was obviously higher than in AA carriers (P<0.001). As compared with patients with TT genotype in VKORC1 1173 C/T, warfarin maintenance dose was apparently higher in patients with CT genotype (P<0.001). Linear regression analysis revealed that gender, operation method, method for heart valve replacement, as well as VKORC1–1639 G/A and 1173 C/T gene polymorphisms were significantly related to warfarin maintenance dose (all P<0.05). Conclusions VKORC1 gene polymorphisms are key genetic factors to affect individual differences in warfarin maintenance dose in patients undergoing cardiac valve replacement; meanwhile, gender, operation method and method for heart valve replacement might also be correlate with warfarin maintenance dose.
Collapse
Affiliation(s)
- Xiaojuan Yan
- Department of Respiratory Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei College of Arts and Science, Xiangyang, Hubei, China (mainland)
| | - Feng Yang
- Department of Cardiovascular Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei College of Arts and Science, Xiangyang, Hubei, China (mainland)
| | - Hanyun Zhou
- Department of Cardiovascular Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei College of Arts and Science, Xiangyang, Hubei, China (mainland)
| | - Hongshen Zhang
- Department of Cardiovascular Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei College of Arts and Science, Xiangyang, Hubei, China (mainland)
| | - Jianfei Liu
- Department of Cardiovascular Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei College of Arts and Science, Xiangyang, Hubei, China (mainland)
| | - Kezhong Ma
- Department of Cardiovascular Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei College of Arts and Science, Xiangyang, Hubei, China (mainland)
| | - Yi Li
- Department of Pharmacy, Ministry of Health Beijing Hospital, Beijing, China (mainland)
| | - Jun Zhu
- Medical Department, Henan Provincial Corps Hospital of Chinese People's Armed Police Force, Zhengzhou, Henan, China (mainland)
| | - Jianqiang Ding
- Medical Department, Henan Provincial Corps Hospital of Chinese People's Armed Police Force, Zhengzhou, Henan, China (mainland)
| |
Collapse
|
46
|
|
47
|
Cressman AM, Macdonald EM, Yao Z, Austin PC, Gomes T, Paterson JM, Kapral MK, Mamdani MM, Juurlink DN. Socioeconomic status and risk of hemorrhage during warfarin therapy for atrial fibrillation: A population-based study. Am Heart J 2015; 170:133-40, 140.e1-3. [PMID: 26093874 DOI: 10.1016/j.ahj.2015.03.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Among patients taking warfarin, lower socioeconomic status is associated with poorer control of anticoagulation. However, the extent to which socioeconomic status influences the risk of hemorrhage is unknown. We examined the extent to which socioeconomic status influences the risk of hemorrhage in older individuals newly commencing warfarin therapy for atrial fibrillation. METHODS We conducted a population-based cohort study of individuals 66 years or older with atrial fibrillation who commenced warfarin therapy between April 1, 1997, and November 30th 2011, in Ontario, Canada. We used neighborhood-level income quintiles as a measure of socioeconomic status. The primary outcome was an emergency department visit or hospitalization for hemorrhage, and the secondary outcome was fatal hemorrhage. RESULTS We studied 166,742 older patients with atrial fibrillation who commenced warfarin therapy. Of these, 16,371 (9.8%) were hospitalized for hemorrhage during a median follow-up of 369 (interquartile range 102-865) days. After multivariable adjustment using Cox proportional hazards regression, we found that those in the lowest-income quintile faced an increased risk of hospitalization for hemorrhage relative to those in the highest quintile (adjusted hazard ratio 1.18, 95% CI 1.12-1.23). Similarly, the risk of fatal hemorrhage (n = 1,802) was increased in the lowest-income relative to the highest-income quintile (adjusted hazard ratio 1.28, 95% CI 1.11-1.48). CONCLUSIONS Among older individuals receiving warfarin therapy for atrial fibrillation, lower socioeconomic status is a risk factor for hemorrhage and hemorrhage-related mortality. This factor should be carefully considered when initiating and monitoring warfarin therapy.
Collapse
|
48
|
Ticagrelor versus clopidogrel in Asian patients with acute coronary syndrome: A retrospective analysis from the Platelet Inhibition and Patient Outcomes (PLATO) Trial. Am Heart J 2015; 169:899-905.e1. [PMID: 26027629 DOI: 10.1016/j.ahj.2015.03.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 03/18/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND In the PLATO trial, ticagrelor was superior to clopidogrel in reducing cardiovascular events among patients with acute coronary syndrome (ACS) at the expense of increased nonfatal bleeding. Because Asian patients, when compared with non-Asian patients, are believed to be more susceptible to bleeding, we evaluated the effects of ticagrelor compared with clopidogrel in Asian (n=1,106) and non-Asian (n=17,515) patients with acute coronary syndrome enrolled in the PLATO study. METHODS AND RESULTS Interaction between Asian/non-Asian and primary efficacy end point (a composite of vascular death, myocardial infarction, and stroke) and net clinical benefit (composite of primary efficacy end point and coronary artery bypass graft [CABG] surgery or non-CABG-related major bleeding) were evaluated with a Cox proportional hazards model. Baseline demographics and comorbidities were different between Asians and non-Asians. The overall cardiovascular event rates were higher in Asians, but bleeding rates were similar. Despite these observed differences, the effects of ticagrelor versus clopidogrel were not significantly different between Asians and non-Asians with respect to the primary efficacy outcome (hazard ratio for Asians vs non-Asians, 0.84 [95% CI 0.61-1.17] vs 0.85 [95% CI 0.77-0.93], P=.974), net clinical benefit (0.85 [95% CI 0.65-1.11] vs 0.93 [95% CI 0.86-0.99], P=.521), or individual efficacy end points. There was no significant interaction for bleeding (PLATO major bleeding, 1.02 [95% CI 0.70-1.49] vs 1.04 [95% CI 0.95-1.14], P=.938) and other related adverse events with ticagrelor compared with clopidogrel between Asians and non-Asians. CONCLUSIONS We observed consistency of effects in Asian patients receiving ticagrelor and clopidogrel in the PLATO study. The relatively modest number of Asian patients in this analysis supports further investigation of larger cohorts to confirm our observations.
Collapse
|
49
|
Hatta FH, Lundblad M, Ramsjo M, Kang JH, Roh HK, Bertilsson L, Eliasson E, Aklillu E. Differences inCYP2C9Genotype and Enzyme Activity Between Swedes and Koreans of Relevance for Personalized Medicine: Role of Ethnicity, Genotype, Smoking, Age, and Sex. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2015; 19:346-53. [DOI: 10.1089/omi.2015.0022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Fazleen H.M. Hatta
- Department of Laboratory Medicine, Karolinska Institutet, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Sweden
- Integrative Pharmacogenomics Institute (iPROMISE), Faculty of Pharmacy, Universiti Teknologi MARA, Selangor, Malaysia
| | - Mia Lundblad
- Department of Laboratory Medicine, Karolinska Institutet, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Sweden
| | - Margareta Ramsjo
- Department of Laboratory Medicine, Karolinska Institutet, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Sweden
| | - Ju-Hee Kang
- Department of Clinical Pharmacology, Inha University School of Medicine and Clinical Pharmacology, Inha University Hospital, Inha University, Incheon, Korea
| | - Hyung-Keun Roh
- Department of Internal Medicine, Division of Clinical Pharmacology, Gachon University Hospital, Incheon, Korea
| | - Leif Bertilsson
- Department of Laboratory Medicine, Karolinska Institutet, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Sweden
| | - Erik Eliasson
- Department of Laboratory Medicine, Karolinska Institutet, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Sweden
| | - Eleni Aklillu
- Department of Laboratory Medicine, Karolinska Institutet, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Sweden
| |
Collapse
|
50
|
Akinboboye O. Use of oral anticoagulants in African-American and Caucasian patients with atrial fibrillation: is there a treatment disparity? J Multidiscip Healthc 2015; 8:217-28. [PMID: 26056467 PMCID: PMC4445875 DOI: 10.2147/jmdh.s74529] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is a very common cardiac arrhythmia, and its prevalence is increasing along with aging in the developed world. This review discusses racial differences in the epidemiology and treatment of AF between African-American and Caucasian patients. Additionally, the effect of race on warfarin and novel oral anticoagulant use is discussed, as well as the role that physicians and patients play in achieving optimal treatment outcomes. Despite having a lower prevalence of AF compared with Caucasians, African-Americans suffer disproportionately from stroke and its sequelae. The possible reasons for this paradox include poorer access to health care, lower health literacy, and a higher prevalence of other stroke-risk factors among African-Americans. Consequently, it is important for providers to evaluate the effects of race, health literacy, access to health care, and cultural barriers on the use of anticoagulation in the management of AF. Warfarin-dose requirements vary across racial groups, with African-American patients requiring a higher dose than Caucasians to maintain a therapeutic international normalized ratio; the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) seem to differ in this regard, although data are currently limited. Minority racial groups are not proportionally represented in either real-world studies or clinical trials, but as more information becomes available and other social issues are addressed, the treatment disparities between African-American and Caucasian patients should decrease.
Collapse
|