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Anand A, Hegde NC, Chhabra P, Purohit J, Kumar R, Gupta A, Lad DP, Mohindra R, Mehrotra S, Vijayvergiya R, Kumar B, Sharma V, Malhotra P, Ahluwalia J, Das R, Patil AN, Shafiq N, Malhotra S. Pharmacogenetic guided versus standard warfarin dosing for routine clinical care with its pharmacoeconomic impact: a randomized controlled clinical trial. Ann Hematol 2024; 103:2133-2144. [PMID: 38634917 DOI: 10.1007/s00277-024-05757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/11/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Empirical use of pharmacogenetic test(PGT) is advocated for many drugs, and resource-rich setting hospitals are using the same commonly. The clinical translation of pharmacogenetic tests in terms of cost and clinical utility is yet to be examined in hospitals of low middle income countries (LMICs). AIM The present study assessed the clinical utility of PGT by comparing the pharmacogenetically(PGT) guided- versus standard of care(SOC)- warfarin therapy, including the health economics of the two warfarin therapies. METHODS An open-label, randomized, controlled clinical trial recruited warfarin-receiving patients in pharmacogenetically(PGT) guided- versus standard of care(SOC)- study arms. Pharmacogenetic analysis of CYP2C9*2(rs1799853), CYP2C9*3(rs1057910) and VKORC1(rs9923231) was performed for patients recruited to the PGT-guided arm. PT(Prothrombin Time)-INR(international normalized ratio) testing and dose titrations were allowed as per routine clinical practice. The primary endpoint was the percent time spent in the therapeutic INR range(TTR) during the 90-day observation period. Secondary endpoints were time to reach therapeutic INR(TRT), the proportion of adverse events, and economic comparison between two modes of therapy in a Markov model built for the commonest warfarin indication- atrial fibrillation. RESULTS The study enrolled 168 patients, 84 in each arm. Per-protocol analysis showed a significantly high median time spent in therapeutic INR in the genotype-guided arm(42.85%; CI 21.4-66.75) as compared to the SOC arm(8.8%; CI 0-27.2)(p < 0.00001). The TRT was less in the PG-guided warfarin dosing group than the standard-of-care dosing warfarin group (17.85 vs. 33.92 days) (p = 0.002). Bleeding and thromboembolic events were similar in the two study groups. Lifetime expenditure was ₹1,26,830 in the PGT arm compared to ₹1,17,907 in the SOC arm. The QALY gain did not differ in the two groups(3.9 vs. 3.65). Compared to SOC, the incremental cost-utility ratio was ₹35,962 per QALY gain with PGT test opting. In deterministic and probabilistic sensitivity analysis, the base case results were found to be insensitive to the variation in model parameters. In the cost-effectiveness-acceptability curve analysis, a 90% probability of cost-effectiveness was reached at a willingness-to-pay(WTP) of ₹ 71,630 well below one time GDP threshold of WTP used. CONCLUSION Clinical efficacy and the cost-effectiveness of the warfarin pharmacogenetic test suggest its routine use as a point of care investigation for patient care in LMICs.
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Affiliation(s)
- Aishwarya Anand
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Naveen C Hegde
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Pulkit Chhabra
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jai Purohit
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rupesh Kumar
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ankur Gupta
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepesh P Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Ritin Mohindra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Saurabh Mehrotra
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Basant Kumar
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Reena Das
- Department of Hematology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amol N Patil
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Samir Malhotra
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Rostán S, Porto S, Barbosa CLN, Assis D, Alvarez N, Machado FS, Mahler G, Otero L. A novel palladium complex with a coumarin-thiosemicarbazone hybrid ligand inhibits Trypanosoma cruzi release from host cells and lowers the parasitemia in vivo. J Biol Inorg Chem 2023; 28:711-723. [PMID: 37768364 DOI: 10.1007/s00775-023-02020-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
In this work, two analogous coumarin-thio and semicarbazone hybrid compounds were prepared and evaluated as a potential antichagasic agents. Furthermore, palladium and platinum complexes with the thiosemicarbazone derivative as ligand (L1) were obtained in order to establish the effect of metal complexation on the antiparasitic activity. All compounds were fully characterized both in solution and in solid state including the resolution of the crystal structure of the palladium complex by X-ray diffraction methods. Unexpectedly, all experimental and theoretical characterizations in the solid state, demonstrated that the obtained palladium and platinum complexes are structurally different: [PdCl(L1)] and [PtCl2(HL1)]. All the studied compounds lower the proliferation of the amastigote form of Trypanosoma cruzi while some of them also have an effect on the trypomastigote stage. Additionally, the compounds inhibit T. cruzi release from host cells in variable extents. The Pd compound presented a remarkable profile in all the in vitro experiments, and it showed no toxicity for mammalian cells in the assayed concentrations. In this sense, in vivo experiments were performed for this compound using an acute model of Chagas disease. Results showed that the complex significantly lowered the parasite count in the mice blood with no significant toxicity.
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Affiliation(s)
- Santiago Rostán
- Graduate Program in Chemistry, Facultad de Química, Universidad de La República, Montevideo, Uruguay
- Área Química Inorgánica, Departamento Estrella Campos, Facultad de Química, Universidad de La República, Montevideo, Uruguay
| | - Samuel Porto
- Laboratorio de Inmunorregulación y Enfermedades Infecciosas (LIDIN), Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | - Cesar L N Barbosa
- Laboratorio de Inmunorregulación y Enfermedades Infecciosas (LIDIN), Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | - Diego Assis
- Laboratorio de Inmunorregulación y Enfermedades Infecciosas (LIDIN), Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | - Natalia Alvarez
- Área Química Inorgánica, Departamento Estrella Campos, Facultad de Química, Universidad de La República, Montevideo, Uruguay
| | - Fabiana Simão Machado
- Laboratorio de Inmunorregulación y Enfermedades Infecciosas (LIDIN), Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | - Graciela Mahler
- Laboratorio de Química Farmacéutica, Departamento de Química Orgánica, Facultad de Química, Universidad de La República, Montevideo, Uruguay
| | - Lucía Otero
- Área Química Inorgánica, Departamento Estrella Campos, Facultad de Química, Universidad de La República, Montevideo, Uruguay.
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Chakraborty S, Paul B, Natarajan R, Hossain J, Majumdar S. Ecofriendly Approach for the Large‐Scale Synthesis of 4‐Unsubstituted Coumarin‐3‐carboxylic Acids from o‐Hydroxy‐araldehydes with Meldrum's Acid in the Water‐SDS Micellar System. ChemistrySelect 2023. [DOI: 10.1002/slct.202204128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Sourav Chakraborty
- Department of Chemistry Tripura University Suryamaninagar 799 022 Tripura India
| | - Bhaswati Paul
- CSIR-Indian Institute of Chemical Biology 4, Raja S. C. Mullick Road Jadavpur Kolkata 700032 India
| | - Ramalingam Natarajan
- CSIR-Indian Institute of Chemical Biology 4, Raja S. C. Mullick Road Jadavpur Kolkata 700032 India
| | - Jewel Hossain
- Department of Chemistry Ramthakur College Agartala 799 003 India
| | - Swapan Majumdar
- Department of Chemistry Tripura University Suryamaninagar 799 022 Tripura India
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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.
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Chaudhary D, Bedi P, Santra S, Pramanik T. Synthesis and Biological Properties of Coumarin Analogue: A Brief
Review. LETT ORG CHEM 2022. [DOI: 10.2174/1570178618666210202152452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
:
One of the most prominent aromatic organic chemical compound is Coumarin having formula C9H6O2 which
is widely known for its benefits in drug industry. Colourless crystalline solid having sweet scent is coumarin’s physical
identity. It serves various purposes such as in synthesis of medicines, laser dyes, perfumes and many more. Having enormous
usages it becomes important to synthesize such compound so various reactions were performed in order to obtain coumarins.
This review explicates the preparation of coumarin by Pechmann Condensation and its biological characteristics.
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Affiliation(s)
- Diksha Chaudhary
- Department of Chemistry, School of Chemical Engineering and Physical Science, Faculty of Technology and Sciences,
Lovely Professional University, Phagwara, P.O.Box 144411, India
| | - Pooja Bedi
- Department of Chemistry, School of Chemical Engineering and Physical Science, Faculty of Technology and Sciences,
Lovely Professional University, Phagwara, P.O.Box 144411, India
| | - Soumava Santra
- Department of Chemistry, School of Chemical Engineering and Physical Science, Faculty of Technology and Sciences,
Lovely Professional University, Phagwara, P.O.Box 144411, India
| | - Tanay Pramanik
- Department of Chemistry, University of Engineering
and Management, University Area, Action Area III, B/5, Newtown, Kolkata-700160, India
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6
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Rostán S, Alvarez N, Veiga N, Otero L, Mahler G. New preparation protocols for coumarin-thiosemicarbazone hybrids: Solid state characterization, and in silico/NMR studies of the Z/E isomerization equilibria in solution. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2021.131980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Srivastava V, Singh PK, Tivari S, Singh PP. Visible light photocatalysis in the synthesis of pharmaceutically relevant heterocyclic scaffolds. Org Chem Front 2022. [DOI: 10.1039/d1qo01602d] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Visible light and photoredox catalysis have emerged as a powerful and long-lasting tool for organic synthesis, demonstrating the importance of a variety of chemical bond formation methods.
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Affiliation(s)
- Vishal Srivastava
- Department of Chemistry, CMP Degree College, University of Allahabad, Prayagraj 211002, India
| | - Pravin K. Singh
- Department of Chemistry, CMP Degree College, University of Allahabad, Prayagraj 211002, India
| | - Shraddha Tivari
- Department of Chemistry, CMP Degree College, University of Allahabad, Prayagraj 211002, India
| | - Praveen P. Singh
- Department of Chemistry, United College of Engineering & Research, Naini, Prayagraj 211010, India
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8
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Yahyazadehfar M, Ahmadi SA, Sheikhhosseini E, Ghazanfari D. Bentonite Catalyzed an Efficient and Green Synthesis of Arylidene Meldrum's Acid Derivatives in Aqueous Media. LETT ORG CHEM 2021. [DOI: 10.2174/1570178617999200807155325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the present paper, a simple, highly efficient, and environmentally friendly protocol
was proposed for the Knoevenagel condensation reaction of aromatic aldehydes using Meldrum’s acid
(2,2-dimethyl-4,6-dioxo-1,3-dioxane) with bentonite as an available non-toxic mineral catalyst exposed
to aqueous media under green conditions. Together with the substitution protocol of electron-donating
or -withdrawing groups, all reactions were finalized from 5 to 120 min in water at 90°C. With regard to
such reactions, the purification of columns on products was not a requirement. Considering the environmental
aspect, use of water as a green solvent, utilization of a reusable catalyst, simple work-up
process and steps, as well as rapid reaction times were taken into account as some characteristics of
these chemical reactions.
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Affiliation(s)
| | - Sayed Ali Ahmadi
- Department of Chemistry, Kerman Branch, Islamic Azad University, Kerman,Iran
| | | | - Dadkhoda Ghazanfari
- Department of Chemistry, Kerman Branch, Islamic Azad University, Kerman,Iran
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9
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Velizarova M, Hristova J, Svinarov D, Ivanova S, Jovinska S, Abedinov P. The impact of CYP2C9 and VKORC1 genetic polymorphisms in anticoagulant therapy management after cardiac surgery with extracorporeal circulation. PHARMACIA 2021. [DOI: 10.3897/pharmacia.68.e63409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Extracorporeal circulation during cardiac surgery is characterized with increased risk for hypercoagulation because blood is exposed to foreign, nonendothelial cell surfaces. Thus, the usage of extracorporeal circulation is essentially not possible without anticoagulation. Open-heart surgery as well as many perioperative factors, such as acidosis, hypocalcemia, hypothermia, and hemodilution, might affect hemostasis and lead to coagulopathy and bleeding. A new insight into the effectiveness of anticoagulant therapy is applied to modify the dosing regimen with respect to the genetic CYP2C9 and VKORC1allelic variants. A systematic literature search was performed for VKORC1 and CYP2C9 and their association with coumarin anticoagulant therapy and bleeding risk in postoperative period of cardiac surgery with extracorporeal circulation.
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Johnson D, Hughes D, Pirmohamed M, Jorgensen A. Evidence to Support Inclusion of Pharmacogenetic Biomarkers in Randomised Controlled Trials. J Pers Med 2019; 9:E42. [PMID: 31480618 PMCID: PMC6789450 DOI: 10.3390/jpm9030042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 01/01/2023] Open
Abstract
Pharmacogenetics and biomarkers are becoming normalised as important technologies to improve drug efficacy rates, reduce the incidence of adverse drug reactions, and make informed choices for targeted therapies. However, their wider clinical implementation has been limited by a lack of robust evidence. Suitable evidence is required before a biomarker's clinical use, and also before its use in a clinical trial. We have undertaken a review of five pharmacogenetic biomarker-guided randomised controlled trials (RCTs) and evaluated the evidence used by these trials to justify biomarker inclusion. We assessed and quantified the evidence cited in published rationale papers, or where these were not available, obtained protocols from trial authors. Very different levels of evidence were provided by the trials. We used these observations to write recommendations for future justifications of biomarker use in RCTs and encourage regulatory authorities to write clear guidelines.
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Affiliation(s)
- Danielle Johnson
- Institute of Translational Medicine, Department of Biostatistics, University of Liverpool, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK.
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Ardudwy, Normal Site, Bangor LL57 2PZ, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Andrea Jorgensen
- Institute of Translational Medicine, Department of Biostatistics, University of Liverpool, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
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11
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Verification of pharmacogenomics-based algorithms to predict warfarin maintenance dose using registered data of Japanese patients. Eur J Clin Pharmacol 2019; 75:901-911. [DOI: 10.1007/s00228-019-02656-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
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Patel JP, Byrne RA, Patel RK, Arya R. Progress in the monitoring of direct oral anticoagulant therapy. Br J Haematol 2019; 184:912-924. [DOI: 10.1111/bjh.15756] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jignesh P. Patel
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
- Institute of Pharmaceutical Science; King's College London; London UK
| | - Rosalind A. Byrne
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
| | - Raj K. Patel
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
| | - Roopen Arya
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
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13
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Maagdenberg H, Bierings MB, van Ommen CH, van der Meer FJ, Appel IM, Tamminga RY, Cessie SL, Swen JJ, der Straaten TV, Boer AD, Maitland-van der Zee AH. Effects of age and genetic variations in VKORC1, CYP2C9 and CYP3A4 on the phenprocoumon dose in pediatric patients. Pharmacogenomics 2018; 19:1195-1202. [PMID: 30207196 DOI: 10.2217/pgs-2018-0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
AIM To study the effects of clinical and genetic factors on the phenprocoumon dose requirement in pediatric patients and to develop a dosing algorithm. METHODS Pediatric patients who used phenprocoumon were invited to participate in a retrospective follow-up study. Clinical information and genotypes of genetic variations in CYP2C9, VKORC1, CYP4F2, CYP2C18 and CYP3A4 were collected and tested with linear regression for association with phenprocoumon dose requirement. RESULTS Of the 41 patients included in the analysis, age, VKORC1, CYP2C9*2/*3 and CYP3A4*1B were statistically significantly associated with dose requirement, and together explained 80.4% of the variability in phenprocoumon dose requirement. CONCLUSION Our study reveals that age and genetic variations explain a significant part of the variability in phenprocoumon dose requirement in pediatric patients.
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Affiliation(s)
- Hedy Maagdenberg
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Marc B Bierings
- Department of Pediatric Stem Cell Transplantation, Princess Maxima Center for pediatric oncology/Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Oncology/Hematology, Erasmus MC/Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Felix Jm van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Inge M Appel
- Department of Pediatric Oncology/Hematology, Erasmus MC/Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rienk Yj Tamminga
- Department of Pediatric Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Saskia le Cessie
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tahar van der Straaten
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Anke H Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.,Department of Respiratory Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Pirmohamed M. Warfarin: The End or the End of One Size Fits All Therapy? J Pers Med 2018; 8:jpm8030022. [PMID: 29958440 PMCID: PMC6163581 DOI: 10.3390/jpm8030022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022] Open
Abstract
Oral anticoagulants are required for both treatment and prophylaxis in many different diseases. Clinicians and patients now have a choice of oral anticoagulants, including the vitamin K antagonists (of which warfarin is the most widely used and is used as the exemplar in this paper), and direct oral anticoagulants (DOACs: dabigatran, apixaban, rivaroxaban, and edoxaban). This paper explores the recent advances and controversies in oral anticoagulation. While some commentators may favour a complete switchover to DOACs, this paper argues that warfarin still has a place in therapy, and a stratified approach that enables the correct choice of both drug and dose would improve both patient outcomes and affordability.
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Affiliation(s)
- Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool L69 3GL, UK.
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15
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Lee JM, Joung B, Cha MJ, Lee JH, Lim WH, Kim TH, Shin SY, Uhm JS, Lim HE, Kim JB, Kim JS. 2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial Fibrillation. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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16
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Limdi NA, Brown TM, Shendre A, Liu N, Hill CE, Beasley TM. Quality of anticoagulation control and hemorrhage risk among African American and European American warfarin users. Pharmacogenet Genomics 2018; 27:347-355. [PMID: 28806200 DOI: 10.1097/fpc.0000000000000298] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We evaluated whether percent time in target range (PTTR), risk of over-anticoagulation [international normalized ratio (INR)>4], and risk of hemorrhage differ by race. As PTTR is a strong predictor of hemorrhage risk, we also determined the influence of PTTR on the risk of hemorrhage by race. PARTICIPANTS AND METHODS Among 1326 warfarin users, PTTR was calculated as the percentage of interpolated INR values within the target range of 2.0-3.0. PTTR was also categorized as poor (PTTR<60%), good (60≤PTTR<70%), or excellent (PTTR≥70%) anticoagulation control. Over-anticoagulation was defined as INR more than 4 and major hemorrhages included serious, life-threatening, and fatal bleeding episodes. Logistic regression and survival analyses were carried out to evaluate the association of race with PTTR (≥60 vs. <60) and major hemorrhages, respectively. RESULTS Compared with African Americans, European Americans had higher PTTR (57.6 vs. 49.1%; P<0.0001) and were more likely to attain 60≤PTTR<70% (22.9 vs. 13.1%; P<0.001) or PTTR of at least 70% (26.9 vs. 18.2%; P=0.001). Older (>65 years) patients without venous thromboembolism indication and chronic kidney disease were more likely to attain PTTR of at least 60%. After accounting for clinical and genetic factors, and PTTR, African Americans had a higher risk of hemorrhage [hazard ratio (HR)=1.58; 95% confidence interval (CI): 1.04-2.41; P=0.034]. Patients with 60≤PTTR<70% (HR=0.62; 95% CI: 0.38-1.02; P=0.058) and PTTR of at least 70% (HR=0.27; 95% CI: 0.15-0.49; P<0.001) had a lower risk of hemorrhage compared with those with PTTR less than 60%. CONCLUSION Despite the provision of warfarin management through anticoagulation clinics, African Americans achieve a lower overall PTTR and have a significantly higher risk of hemorrhage. Personalized medicine interventions tailored to African American warfarin users need to be developed.
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Affiliation(s)
- Nita A Limdi
- aDepartment of Neurology bDepartment of Medicine, Division of Cardiovascular Diseases cDepartment of Epidemiology dDepartment of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA eDepartment of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
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17
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Ajmi M, Omezzine A, Achour S, Amor D, Hamdouni H, Ismaïl FBF, Rejeb NB, Kechrid CL, Boughzela E, Bouslama A. Influence of genetic and non-genetic factors on acenocoumarol maintenance dose requirement in a Tunisian population. Eur J Clin Pharmacol 2018; 74:711-722. [PMID: 29479633 DOI: 10.1007/s00228-018-2423-7] [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: 10/12/2017] [Accepted: 01/23/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE We aimed to study potential variables involved in interindividual variability to acenocoumarol (AC) response in order to establish a pharmacogenetic algorithm (PA) that includes clinical and genetic factors to predict adequate AC dose to stabilize anticoagulation in a cohort of Tunisian patients. METHODS Genotyping of the CYP2C9, VKORC1, CYP4F2, and CALU polymorphisms was conducted on 246 patients using PCR-RFLP technique. AC normalized maintenance dose (NMD): ((mean maintenance dose/international normalized ratio (INR)) equilibrium) was calculated. The statistical study was carried out with SPSS V20. RESULTS A significant correlation was found between age, BMI, and daily AC dose (r = - 0.397; p < 0.001 and r = 0.215; p = 0.001, respectively). The carriers of mutated alleles CYP2C9*2 or CYP2C9*3 or VKORC1 haplotypes (H1 and H7) were associated with AC hyper-sensibility. After adjustment to potential covariates, these patients presented supra-therapeutic INR during treatment period and needed low AC dose (ORs* = 0.28 [0.06-0.60], p = 0.004; ORs* = 0.12 [0.04-0.05], p < 0.001; ORs* = 0.45 [0.24-0.84], p = 0.01; and ORs* = 0.28 [0.06-0.98], p = 0.049, respectively). However, carriers of VKORC1 haplotypes (H3 and H12) or mutated alleles CYP4F2 (rs2108622) or CALU (rs1043550) tend to resist to treatment, hence long period of therapy initiation, and must be treated with high AC dose (ORs* = 2.67 [81.12-5.91], p = 0.013; ORs* = 8.76 [1.07-76.26], p = 0.019; ORs* = 3.12 [1.01-9.63], p = 0.047; and ORs* = 3.96 [1.41-11.09], p = 0.009, respectively). A final multivariate regression model explained 48.1% of the global interindividual variability in AC dose requirement. CONCLUSION The PA demonstrated that VKORC1 and CYP2C9 polymorphisms contribution was more important than clinical factors. Applying the PA would allow dose adjustment to treat patients in a personalized manner.
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Affiliation(s)
- Marwa Ajmi
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia. .,Higher Institute of Biotechnology of Monastir, University of Monastir, Monastir, Tunisia.
| | - Asma Omezzine
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia.,Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Slim Achour
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia
| | - Dorra Amor
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia
| | - Haithem Hamdouni
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia.,Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | | | - Nabila Ben Rejeb
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia.,Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | | | - Essia Boughzela
- Cardiology Department, Sahloul University Hospital, Sousse, Tunisia
| | - Ali Bouslama
- LR12SP11, Biochemistry Department, Sahloul University Hospital, Sousse, Tunisia.,Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
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18
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Ragia G, Karantza IM, Kelli-Kota E, Kolovou V, Kolovou G, Konstantinides S, Maltezos E, Tavridou A, Tziakas D, Maitland-van der Zee AH, Manolopoulos VG. Role of CYP4F2, CYP2C19, and CYP1A2 polymorphisms on acenocoumarol pharmacogenomic algorithm accuracy improvement in the Greek population: need for sub-phenotype analysis. Drug Metab Pers Ther 2017; 32:183-190. [PMID: 29252193 DOI: 10.1515/dmpt-2017-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND We have earlier developed a pharmacogenomic algorithm for acenocoumarol dose prediction in Greek patients that included CYP2C9/VKORC1 genetic information. This study aims at analyzing the potential effect of CYP4F2, CYP2C19, and CYP1A2 gene polymorphisms on acenocoumarol dose requirements and at further improving the Greek-specific pharmacogenomic algorithm. METHODS A total of 205 Greek patients taking acenocoumarol (140 who reached and 65 who did not reach stable dose), participants of acenocoumarol EU-PACT trial, were included in the study. CYP4F2, CYP2C19, and CYP1A2 polymorphisms were genotyped by use of the PCR-RFLP method. All patients were previously genotyped for CYP2C9/VKORC1 polymorphisms. RESULTS In the pooled sample, CYP4F2, CYP2C19, and CYP1A2 polymorphisms do not affect independently acenocoumarol dose requirements. For CYP4F2, significant effects were found on patients' ability to reach stable dose and on acenocoumarol dose requirements when CYP2C9/VKORC1 sub-phenotypes were analyzed. Specifically, when the patients were stratified according to their CYP2C9/VKORC1 functional bins, in sensitive responders, CYP4F2*3 allele carriers (CYP4F2 *1/*3 and *3/*3 genotypes) were more frequent in the patient group who reached stable dose (p=0.049). Additionally, in CYP2C9 intermediate metabolizers (IMs), after adjusting for age, weight, and VKORC1 genotypes, CYP4F2 genotypes were significantly associated with acenocoumarol stable dose (β: 0.07; 95% CI: 0.006-0.134; p=0.033). CONCLUSIONS CYP4F2 gene shows a prominent weak association with acenocoumarol dose requirements. Sub-phenotype analysis is potentially important in determining additional gene polymorphisms that are associated with acenocoumarol dose requirements.
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Affiliation(s)
- Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Dragana Campus, 68100 Alexandroupolis, Greece, Phone: +30 2551 030523, Fax: +30 2551 030523; and DNALEX S.A., Alexandroupolis, Greece
| | - Ioanna-Maria Karantza
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Eleni Kelli-Kota
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vana Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Genovefa Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Konstantinides
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anna Tavridou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Tziakas
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anke H Maitland-van der Zee
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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19
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Varnai R, Sipeky C, Nagy L, Balogh S, Melegh B. CYP2C9 and VKORC1 in therapeutic dosing and safety of acenocoumarol treatment: implication for clinical practice in Hungary. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2017; 56:282-289. [PMID: 29055218 DOI: 10.1016/j.etap.2017.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/29/2017] [Accepted: 10/07/2017] [Indexed: 06/07/2023]
Abstract
The purpose of this work was to investigate the contribution of CYP2C9 and VKORC1 to acenocoumarol (AC) dose variability, bleeding events in Hungary. The study recruited 117 patients on long-term AC therapy (INR 2-3), and 510 healthy individuals to model the findings. Patients were genotyped for alleles proved to affect lower AC overdose CYP2C9*2, CYP2C9*3, VKORC1*2. Additionally, we tested VKORC1*3, VKORC1*4 to examine their effect in patients with higher AC requirements. Most impact on dose reduction is accountable for CYP2C9*2/*3 (59%) and for VKORC1*2/*2 (45.5%), and on dose increase for newly evaluated VKORC1*3/*4 (22.5%) diplotypes. VKORC1*3 and *4 alleles seem to balance the dose-reducing effect of VKORC1*2 allele. Being a carrier of combination of VKORC1*2 and CYP2C9*2,*3 polymorphisms, rather than of one of these SNPs, is associated with higher risk of over-anticoagulation (up to 34.3%) in long-term AC treatment. The pharmacogenetic dosing algorithm involving VKORC1, CYP2C9 diplotypes and age explains 30.4% of AC dosing variability (p<6.10×10-9). Correlation between the studied diplotypes and bleeding events could not be revealed.
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Affiliation(s)
- Reka Varnai
- University of Pecs, Department of Primary Health Care, H-7623 Pecs, Rakoczi 2, Hungary; University of Pécs, Faculty of Health Sciences, Doctoral School of Health Sciences, H-7621 Pécs, Vörösmarty 4, Hungary
| | - Csilla Sipeky
- University of Pecs, Clinical Centre, Department of Medical Genetics, H-7624 Pecs, Szigeti 12, Hungary.
| | - Lajos Nagy
- University of Pecs, Department of Primary Health Care, H-7623 Pecs, Rakoczi 2, Hungary
| | - Sandor Balogh
- University of Pecs, Department of Primary Health Care, H-7623 Pecs, Rakoczi 2, Hungary
| | - Bela Melegh
- University of Pecs, Clinical Centre, Department of Medical Genetics, H-7624 Pecs, Szigeti 12, Hungary
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20
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Coumarin Derivatives Solvent-Free Synthesis under Microwave Irradiation over Heterogeneous Solid Catalysts. Molecules 2017; 22:molecules22122072. [PMID: 29182553 PMCID: PMC6149690 DOI: 10.3390/molecules22122072] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/15/2017] [Accepted: 11/23/2017] [Indexed: 11/16/2022] Open
Abstract
A suitable methodology of synthesis of coumarin derivatives by Pechmann reaction over heterogeneous solid acid catalysts in a free solvent media under microwave irradiation is described. Resorcinol, phenol and ethyl acetoacetate were selected as model reactants in the Pechmann condensation. The catalytic activity of several materials—Amberlyst-15, zeolite β and sulfonic acid functionalized hybrid silica—in solvent-free microwave-assisted synthesis of the corresponding coumarin derivatives has been investigated in detail. 7-Hydroxy-4-methylcoumarin and 4-methylcoumarin were obtained in 97% and 43% yields, respectively, over Amberlyst-15. This was the most active catalyst in the Pechmann reaction under studied conditions.
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21
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Avdović EH, Milenković D, Dimitrić-Marković JM, Vuković N, Trifunović SR, Marković Z. Structural, spectral and NBO analysis of 3-(1-(3-hydroxypropylamino)ethylidene)chroman-2,4-dione. J Mol Struct 2017. [DOI: 10.1016/j.molstruc.2017.06.094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Kaye JB, Schultz LE, Steiner HE, Kittles RA, Cavallari LH, Karnes JH. Warfarin Pharmacogenomics in Diverse Populations. Pharmacotherapy 2017; 37:1150-1163. [PMID: 28672100 DOI: 10.1002/phar.1982] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Genotype-guided warfarin dosing algorithms are a rational approach to optimize warfarin dosing and potentially reduce adverse drug events. Diverse populations, such as African Americans and Latinos, have greater variability in warfarin dose requirements and are at greater risk for experiencing warfarin-related adverse events compared with individuals of European ancestry. Although these data suggest that patients of diverse populations may benefit from improved warfarin dose estimation, the vast majority of literature on genotype-guided warfarin dosing, including data from prospective randomized trials, is in populations of European ancestry. Despite differing frequencies of variants by race/ethnicity, most evidence in diverse populations evaluates variants that are most common in populations of European ancestry. Algorithms that do not include variants important across race/ethnic groups are unlikely to benefit diverse populations. In some race/ethnic groups, development of race-specific or admixture-based algorithms may facilitate improved genotype-guided warfarin dosing algorithms above and beyond that seen in individuals of European ancestry. These observations should be considered in the interpretation of literature evaluating the clinical utility of genotype-guided warfarin dosing. Careful consideration of race/ethnicity and additional evidence focused on improving warfarin dosing algorithms across race/ethnic groups will be necessary for successful clinical implementation of warfarin pharmacogenomics. The evidence for warfarin pharmacogenomics has a broad significance for pharmacogenomic testing, emphasizing the consideration of race/ethnicity in discovery of gene-drug pairs and development of clinical recommendations for pharmacogenetic testing.
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Affiliation(s)
- Justin B Kaye
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Lauren E Schultz
- Department of Pharmacology and Toxicology, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Rick A Kittles
- Department of Public Health, University of Arizona College of Medicine, Tucson, Arizona.,Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona.,Center for Applied Genetics and Genomic Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, Florida
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona.,Center for Applied Genetics and Genomic Medicine, University of Arizona College of Medicine, Tucson, Arizona.,Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona
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23
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Baranova EV, Verhoef TI, Ragia G, le Cessie S, Asselbergs FW, de Boer A, Manolopoulos VG, Maitland-van der Zee AH. Dosing algorithms for vitamin K antagonists across VKORC1 and CYP2C9 genotypes. J Thromb Haemost 2017; 15:465-472. [PMID: 28063245 DOI: 10.1111/jth.13615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/15/2016] [Indexed: 11/27/2022]
Abstract
Essentials Prospective studies of pharmacogenetic-guided (PG) coumarin dosing produced varying results. EU-PACT acenocoumarol and phenprocoumon trials compared PG and non-PG dosing algorithms. Sub-analysis of EU-PACT identified differences between trial arms across VKORC1-CYP2C9 groups. Adjustment of the PG algorithm might lead to a higher benefit of genotyping. SUMMARY Background The multicenter, single-blind, randomized EU-PACT trial compared the safety and efficacy of genotype-guided and non-genetic dosing algorithms for acenocoumarol and phenprocoumon in patients with atrial fibrillation or deep vein thrombosis. The trial showed no differences in the primary outcome between the two dosing strategies. Objectives To explore possible reasons for the lack of differences between trial arms by performing a secondary analysis of EU-PACT data in order to evaluate the performance of both dosing algorithms across VKORC1-CYP2C9 genetic subgroups. Patients/Methods Anticoagulation control measured according to an International Normalized Ratio (INR) below (INR of < 2), within (INR of 2-3) and above (INR of > 3) the therapeutic range was compared across VKORC1-CYP2C9 subgroups. Owing to a low number of patients in each subgroup, trials for acenocoumarol and phenprocoumon were combined for analysis. Results Four weeks after therapy initiation, genotype-guided dosing increased the mean percentage of time in the therapeutic INR range (PTIR) in the VKORC1 GG-CYP2C9*1*1 subgroup as compared with the non-genetic dosing (difference of 14.68%, 95% confidence interval [CI] 5.38-23.98). For the VKORC1 AA-CYP2C9*1*1 subgroup, there was a higher risk of under-anticoagulation with the genotype-guided algorithm (difference of 19.9%; 95% CI 11.6-28.2). Twelve weeks after therapy initiation, no statistically significant differences in anticoagulation control between trial arms were noted across the VKORC1-CYP2C9 genetic subgroups. Conclusions EU-PACT genetic-guided dose initiation algorithms for acenocoumarol and phenprocoumon could have predicted the dose overcautiously in the VKORC1 AA-CYP2C9*1*1 subgroup. Adjustment of the genotype-guided algorithm could lead to a higher benefit of genotyping.
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Affiliation(s)
- E V Baranova
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - T I Verhoef
- Department of Applied Health Research, University College London, London, UK
| | - G Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - S le Cessie
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
- Durrer Center for Cardiogenetic Research, ICIN-Netherlands Heart Institute, Utrecht, the Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - A de Boer
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - V G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - A H Maitland-van der Zee
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
- Department of Respiratory Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Zhang Y, de Boer A, Verhoef TI, van der Meer FJM, Le Cessie S, Manolopoulos VG, Maitland-van der Zee AH. Age-stratified outcome of a genotype-guided dosing algorithm for acenocoumarol and phenprocoumon. J Thromb Haemost 2017; 15:454-464. [PMID: 27992949 DOI: 10.1111/jth.13601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Indexed: 11/28/2022]
Abstract
Essentials The EU-PACT trial was used to investigate age on the interaction between coumarins and genotype. The results support the use of genotype-guided dosing for phenprocoumon in patients < 75 years. For patients ≥ 75 years the phenprocoumon algorithm should be revised and further tested. No influence of comorbidities and co-current drug use was found that could explain the differences. SUMMARY Background Age seemed to affect the interaction between coumarins and genotype in the acenocoumarol and phenprocoumon arm of the European Pharmacogenetics of Anticoagulant Therapy (EU-PACT) trial. Objectives To investigate the effect of genotype-guided dosing stratified by age and the potential factors causing a difference. Patients/Methods Data from the acenocoumarol/phenprocoumon arm of the EU-PACT trial were used. The percentages of time below the therapeutic range, time above the therapeutic range and time in the therapeutic range (TTR) during the initial 12 weeks of therapy were compared between the genotype-guided group and the control group among younger (< 75 years) and older (≥ 75 years) patients by the use of independent t-tests, and adjusted for sex, height, weight and co-medications by the use of linear regression. Results Among younger phenprocoumon users, TTR during the first 12 weeks in the genotype-guided group (n = 55) was 9.5% (95% confidence interval [CI] 1.3 to 17.8) higher than in the control group (n = 63), with a remarkably lower percentage of time above this range (difference: - 9.6%, 95% CI - 19.0 to - 0.2) and a similar time below this range. Older patients dosed by the genotype-guided algorithm (n = 24) spent more time above the range (difference: 27.5%, 95% CI 12.9 to 42.0). For acenocoumarol users, there were no significant differences between the genotype-guided and control groups for most outcomes, except for a lower percentage of time below the range among older patients. Conclusions The genotype-guided algorithm for phenprocoumon in the EU-PACT trial benefitted younger patients more, but for older patients the algorithm needs to be revised and tested in further research.
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Affiliation(s)
- Y Zhang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - A de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - T I Verhoef
- Department of Applied Health Research, University College London, London, UK
| | - F J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Le Cessie
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - V G Manolopoulos
- Clinical Pharmacology Unit, Academic General Hospital of Evros, Alexandroupolis, Greece
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - A H Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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25
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Ragia G, Kolovou V, Kolovou G, Konstantinides S, Maltezos E, Tavridou A, Tziakas D, Maitland-van der Zee AH, Manolopoulos VG. A novel acenocoumarol pharmacogenomic dosing algorithm for the Greek population of EU-PACT trial. Pharmacogenomics 2017; 18:23-34. [DOI: 10.2217/pgs-2016-0126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To generate and validate a pharmacogenomic-guided (PG) dosing algorithm for acenocoumarol in the Greek population. To compare its performance with other PG algorithms developed for the Greek population. Patients & methods: A total of 140 Greek patients participants of the EU-PACT trial for acenocoumarol, a randomized clinical trial that prospectively compared the effect of a PG dosing algorithm with a clinical dosing algorithm on the percentage of time within INR therapeutic range, who reached acenocoumarol stable dose were included in the study. Results: CYP2C9 and VKORC1 genotypes, age and weight affected acenocoumarol dose and predicted 53.9% of its variability. EU-PACT PG algorithm overestimated acenocoumarol dose across all different CYP2C9/VKORC1 functional phenotype bins (predicted dose vs stable dose in normal responders 2.31 vs 2.00 mg/day, p = 0.028, in sensitive responders 1.72 vs 1.50 mg/day, p = 0.003, in highly sensitive responders 1.39 vs 1.00 mg/day, p = 0.029). The PG algorithm previously developed for the Greek population overestimated the dose in normal responders (2.51 vs 2.00 mg/day, p < 0.001). Conclusion: Ethnic-specific dosing algorithm is suggested for better prediction of acenocoumarol dosage requirements in patients of Greek origin.
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Affiliation(s)
| | - Vana Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Genovefa Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Konstantinides
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anna Tavridou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Evros, Alexandroupolis, Greece
| | - Dimitrios Tziakas
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anke H Maitland-van der Zee
- Division of Pharmacoepidemiology & Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Evros, Alexandroupolis, Greece
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Stingl JC, Just KS, Kaumanns K, Schurig-Urbaniak M, Scholl C, von Mallek D, Brockmöller J. [Personalized drug therapy based on genetics. Possibilities and examples from clinical practice]. Internist (Berl) 2016; 57:289-97. [PMID: 26830424 DOI: 10.1007/s00108-015-0013-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pharmacogenetics are an important component in the individualization of treatment; however, pharmacogenetic diagnostics have so far not been used to any great extent in clinical practice. A consistent consideration of individual patient factors, such as pharmacogenetics may help to improve drug therapy and increase individual safety and efficacy aspects. OBJECTIVE A brief summary of structures and effects of genetic variations on drug efficacy is presented. Some frequently prescribed pharmaceuticals are specified. Furthermore, the feasibility of pharmacogenetic diagnostics and dose recommendations in the clinical practice are described. CURRENT DATA The European Medicines Agency (EMA) as the European approval authority has already extended the drug labels of more than 70 pharmaceuticals by information on pharmacogenetic biomarkers and the U.S. Food and Drug Administration (FDA) more than 150. This is a crucial step towards targeted medicine. Guidelines on dose and therapy adjustments are provided by the Clinical Pharmacogenetics Implementation Consortium of the Pharmacogenomics Research Network. CONCLUSION It is fundamental to consider individual patient factors for successful drug therapy. Dose and therapy recommendations based on pharmacogenetic diagnostics are highly important for individualization as well as improvement of safety and efficiency of drug therapy.
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Affiliation(s)
- J C Stingl
- Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland.
- Zentrum für Translationale Medizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland.
| | - K S Just
- Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
- Zentrum für Translationale Medizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland
| | - K Kaumanns
- Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
- Zentrum für Translationale Medizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland
| | - M Schurig-Urbaniak
- Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
- Zentrum für Translationale Medizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland
| | - C Scholl
- Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
- Zentrum für Translationale Medizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland
| | - D von Mallek
- Abteilung Forschung, Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Deutschland
- Zentrum für Translationale Medizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland
| | - J Brockmöller
- Institut für Klinische Pharmakologie, Universität Göttingen, Göttingen, Deutschland
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4724] [Impact Index Per Article: 590.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1318] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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Sehgal T, Hira JK, Ahluwalia J, Das R, Vijayvergiya R, Rana SS, Varma N. High prevalence of VKORC1*3 (G9041A) genetic polymorphism in north Indians: A study on patients with cardiac disorders on acenocoumarol. Drug Discov Ther 2016; 9:404-10. [PMID: 26781925 DOI: 10.5582/ddt.2015.01066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coumarin derivatives such as warfarin and acenocoumarol are used in various disorders such as deep venous thrombosis, pulmonary embolism, atrial fibrillation and artificial heart valves. They have improved prognosis of patients with thromboembolic disease. An individual's response to coumarins depends on several factors. The non-genetic factors include age, gender, body mass index, diet and interacting drugs. Among the genetic factors, the cytochrome P450 system and vitamin K epoxide reductase complex subunit 1 play a key role in drug metabolism. This was a prospective hospital based study in which allele and genotypic frequencies of CYP2C9 gene polymorphisms; 430C>T and 1075A>C and VKORC1 gene polymorphisms; 1639G>A, 9041G>A and 6009C>T in 106 alleles of north Indian patients with valve replacement on acenocoumarol were determined and their effect on acenocoumarol dosing was studied. To the best of our knowledge, this is first report of VKORC1 9041G>A and 6009C>T gene polymorphisms and their effect on acenocoumarol dosing from north India. In 53 patients with valve replacement on acenocoumarol with stable INR, the allele frequency of CYP2C9*2 and CYP2C9*3 gene polymorphisms was 0.05 and 0.17 respectively and that of VKORC1 *2,*3 and *4 gene polymorphisms was 0.15, 0.72 and 0.11 respectively. The presence of CYP2C9*3 or VKORC1*2 gene polymorphism were associated with decrease in acenocoumarol dose requirements (p values 0.03 and 0.02 respectively).This study confirmed the association of lower mean weekly dosages of acenocoumarol in patients with CYP2C9*3 and VKORC1*2 gene polymorphisms. An unusually high frequency of 9041A polymorphism in VKORC1 was found in study population.
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Affiliation(s)
- Tushar Sehgal
- Department of Hematology, Postgraduate Institute of Medical Education and Research
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31
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Comparison of dosing algorithms for acenocoumarol and phenprocoumon using clinical factors with the standard care in the Netherlands. Thromb Res 2015; 136:94-100. [DOI: 10.1016/j.thromres.2015.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/03/2015] [Accepted: 04/24/2015] [Indexed: 11/23/2022]
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Tzveova R, Dimitrova-Karamfilova A, Saraeva R, Solarova T, Naydenova G, Petrova I, Hristova N, Popov I, Nachev G, Mitev V, Kaneva R. Estimation and validation of acenocoumarol dosing algorithms in Bulgarian patients with cardiovascular diseases. Per Med 2015; 12:209-220. [PMID: 29771648 DOI: 10.2217/pme.14.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim & Methods: A total of 169 Bulgarian patients were genotyped for CYP2C9*2,*3, VKORC1-1639G>A and VKORC11173C>T. The effect of genetic and nongenetic factors on acenocoumarol dose variability was tested in a derivation cohort of patients and the obtained algorithm was validated in a test cohort. RESULTS & DISCUSSION It was found that VKORC-1639G>A (25.5%), CYP2C9*2 (7.8%), CYP2C9*3 (6.1%), age (13.6%) and diagnosis (6.0%) significantly affected acenocoumarol dose variability in the derivation cohort. These factors with additional factors, such as sex (0.1%, p = 0.76), weight (2.6%, p = 0.14) and amiodarone use (3.0%, p = 0.059) accounted for 46.5% and 23.0% of the dose variability for genetic and clinical models, respectively. CONCLUSION Based on the results of this investigation, validated clinical and pharmacogenetic algorithms for the prediction of a stable anticoagulant dose were developed, specifically designed for the Bulgarian population.
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Affiliation(s)
- Reni Tzveova
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Antoaneta Dimitrova-Karamfilova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Radoslava Saraeva
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Tanya Solarova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Galya Naydenova
- Second Department of Cardiology, University NationalMulti-profile Active Treatment Hospital "Dr. G. Stansky"- Pleven, 8A Georgi Kochev str., Pleven 5800, Bulgaria
| | - Irina Petrova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Nataliya Hristova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Ivan Popov
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Gencho Nachev
- Department of Cardiac Surgery, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Vanio Mitev
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Radka Kaneva
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
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Verhoef TI, Redekop WK, Bouvy ML, Dorenbos B, Karwar Z, van Schie RMF, de Boer A, Maitland-van der Zee AH. Beliefs about medicines in Dutch acenocoumarol and phenprocoumon users. Br J Clin Pharmacol 2015; 78:422-9. [PMID: 24528215 DOI: 10.1111/bcp.12346] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 02/04/2014] [Indexed: 11/29/2022] Open
Abstract
AIMS Adherence to the generally complex regimen of coumarin derivatives is vital in order to keep patients in the adequate International Normalized Ratio range. Patients' beliefs about medicines are associated with the level of therapy adherence. Our first aim was to assess beliefs about coumarins. Secondly, we compared the beliefs about coumarins with the beliefs about other cardiovascular drugs. METHODS The Beliefs about Medicines Questionnaire was used to assess medication beliefs. The questionnaire was completed by new users of coumarins indicated for venous thromboembolism or atrial fibrillation. A necessity score and a concerns score were calculated for all patients. The analyses were repeated for users of antihypertensive drugs or statins (not using coumarins). RESULTS Three hundred and twenty patients were included in the analysis of the beliefs about coumarins. The mean necessity score was 15.3, the concerns score 12.3 and the necessity-concerns differential 3.0. Patients with venous thromboembolism (n = 71) had higher necessity scores than patients with atrial fibrillation (n = 249; 16.8 vs. 14.9, P < 0.001). The mean necessity score in 493 users of other cardiovascular drugs was 16.1, the concerns score 13.5 and the necessity-concerns differential 2.6. The necessity score was higher in chronic cardiovascular drug users (n = 192) than in new users (n = 301; 17.9 vs. 14.9, P < 0.001). CONCLUSIONS Coumarin users score higher on the necessity scale than on the concerns scale, which is also the case in users of other cardiovascular drugs. Patients with atrial fibrillation have a less positive attitude towards these drugs than patients with venous thromboembolism, and could therefore benefit more from specific attention.
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Affiliation(s)
- Talitha I Verhoef
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
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Baranova EV, Verhoef TI, Asselbergs FW, de Boer A, Maitland-van der Zee AH. Genotype-guided coumarin dosing: where are we now and where do we need to go next? Expert Opin Drug Metab Toxicol 2015; 11:509-22. [DOI: 10.1517/17425255.2015.1004053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Pharmacogenetics of Coumarin Anticoagulant Therapy. ADVANCES IN PREDICTIVE, PREVENTIVE AND PERSONALISED MEDICINE 2015. [DOI: 10.1007/978-3-319-15344-5_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Francis B, Lane S, Pirmohamed M, Jorgensen A. A review of a priori regression models for warfarin maintenance dose prediction. PLoS One 2014; 9:e114896. [PMID: 25501765 PMCID: PMC4264860 DOI: 10.1371/journal.pone.0114896] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 11/14/2014] [Indexed: 01/21/2023] Open
Abstract
A number of a priori warfarin dosing algorithms, derived using linear regression methods, have been proposed. Although these dosing algorithms may have been validated using patients derived from the same centre, rarely have they been validated using a patient cohort recruited from another centre. In order to undertake external validation, two cohorts were utilised. One cohort formed by patients from a prospective trial and the second formed by patients in the control arm of the EU-PACT trial. Of these, 641 patients were identified as having attained stable dosing and formed the dataset used for validation. Predicted maintenance doses from six criterion fulfilling regression models were then compared to individual patient stable warfarin dose. Predictive ability was assessed with reference to several statistics including the R-square and mean absolute error. The six regression models explained different amounts of variability in the stable maintenance warfarin dose requirements of the patients in the two validation cohorts; adjusted R-squared values ranged from 24.2% to 68.6%. An overview of the summary statistics demonstrated that no one dosing algorithm could be considered optimal. The larger validation cohort from the prospective trial produced more consistent statistics across the six dosing algorithms. The study found that all the regression models performed worse in the validation cohort when compared to the derivation cohort. Further, there was little difference between regression models that contained pharmacogenetic coefficients and algorithms containing just non-pharmacogenetic coefficients. The inconsistency of results between the validation cohorts suggests that unaccounted population specific factors cause variability in dosing algorithm performance. Better methods for dosing that take into account inter- and intra-individual variability, at the initiation and maintenance phases of warfarin treatment, are needed.
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Affiliation(s)
- Ben Francis
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Steven Lane
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Andrea Jorgensen
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
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Verhoef TI, Redekop WK, Daly AK, van Schie RMF, de Boer A, Maitland-van der Zee AH. Pharmacogenetic-guided dosing of coumarin anticoagulants: algorithms for warfarin, acenocoumarol and phenprocoumon. Br J Clin Pharmacol 2014; 77:626-41. [PMID: 23919835 DOI: 10.1111/bcp.12220] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/17/2013] [Indexed: 12/13/2022] Open
Abstract
Coumarin derivatives, such as warfarin, acenocoumarol and phenprocoumon are frequently prescribed oral anticoagulants to treat and prevent thromboembolism. Because there is a large inter-individual and intra-individual variability in dose-response and a small therapeutic window, treatment with coumarin derivatives is challenging. Certain polymorphisms in CYP2C9 and VKORC1 are associated with lower dose requirements and a higher risk of bleeding. In this review we describe the use of different coumarin derivatives, pharmacokinetic characteristics of these drugs and differences amongst the coumarins. We also describe the current clinical challenges and the role of pharmacogenetic factors. These genetic factors are used to develop dosing algorithms and can be used to predict the right coumarin dose. The effectiveness of this new dosing strategy is currently being investigated in clinical trials.
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Affiliation(s)
- Talitha I Verhoef
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht
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Vekariya RH, Patel HD. Recent Advances in the Synthesis of Coumarin Derivatives via Knoevenagel Condensation: A Review. SYNTHETIC COMMUN 2014. [DOI: 10.1080/00397911.2014.926374] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Rajesh H. Vekariya
- a Department of Chemistry, School of Sciences , Gujarat University , Ahmedabad , India
| | - Hitesh D. Patel
- a Department of Chemistry, School of Sciences , Gujarat University , Ahmedabad , India
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Johansen Taber KA, Dickinson BD. Pharmacogenomic knowledge gaps and educational resource needs among physicians in selected specialties. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2014; 7:145-62. [PMID: 25045280 PMCID: PMC4100727 DOI: 10.2147/pgpm.s63715] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The use of pharmacogenomic testing in the clinical setting has the potential to improve the safety and effectiveness of drug therapy, yet studies have revealed that physicians lack knowledge about the topic of pharmacogenomics, and are not prepared to implement it in the clinical setting. This study further explores the pharmacogenomic knowledge deficit and educational resource needs among physicians. MATERIALS AND METHODS Surveys of primary care physicians, cardiologists, and psychiatrists were conducted. RESULTS Few physicians reported familiarity with the topic of pharmacogenomics, but more reported confidence in their knowledge about the influence of genetics on drug therapy. Only a small minority had undergone formal training in pharmacogenomics, and a majority reported being unsure what type of pharmacogenomic tests were appropriate to order for the clinical situation. Respondents indicated that an ideal pharmacogenomic educational resource should be electronic and include such components as how to interpret pharmacogenomic test results, recommendations for prescribing, population subgroups most likely to be affected, and contact information for laboratories offering pharmacogenomic testing. CONCLUSION Physicians continue to demonstrate pharmacogenomic knowledge gaps, and are unsure about how to use pharmacogenomic testing in clinical practice. Educational resources that are clinically oriented and easily accessible are preferred by physicians, and may best support appropriate clinical implementation of pharmacogenomics.
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Affiliation(s)
| | - Barry D Dickinson
- Department of Science and Biotechnology, American Medical Association, Chicago, IL, USA
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Ross S, Paré G. Pharmacogenetics of antiplatelets and anticoagulants: a report on clopidogrel, warfarin and dabigatran. Pharmacogenomics 2014; 14:1565-72. [PMID: 24088127 DOI: 10.2217/pgs.13.149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Genetic polymorphisms are thought to contribute to the wide intraindividual variability in antiplatelet and anticoagulant drug response. Pharmacogenetics is the study of how genetic variants influence drug response and how the adoption of a more personalized approach in antiplatelet and anticoagulant therapy may help to minimize harmful drug effects and optimize care for individual patients. However, due to sometimes conflicting evidence, the uptake of pharmacogenetics in the clinical setting has been slow. In this article, we review the genetic mechanisms contributing to the variability in response to three commonly used and emerging antiplatelet and anticoagulant drug therapies, namely clopidogrel, warfarin and dabigatran. We will focus on common genetic variants that influence the absorption, metabolism and/or action of these agents, including CYP2C19 (*2, *3 and *17), CYP3A4, CYP3A5, CYP2C9, ABCB1, P2RY12, CYP2C9 (*2/*3), VKORC1 and CESI.
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Affiliation(s)
- Stephanie Ross
- Population Health Research Institute, McMaster University, Hamilton General Hospital Campus, DB-CVSRI, 237 Barton Street East, Room C3103, Hamilton, ON L8L 2X2, Canada
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Johnson JA. Pharmacogenetics in clinical practice: how far have we come and where are we going? Pharmacogenomics 2014; 14:835-43. [PMID: 23651030 DOI: 10.2217/pgs.13.52] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Recent years have seen great advances in our understanding of genetic contributors to drug response. Drug discovery and development around targeted genetic (somatic) mutations has led to a number of new drugs with genetic indications, particularly for the treatment of cancers. Our knowledge of genetic contributors to variable drug response for existing drugs has also expanded dramatically, such that the evidence now supports clinical use of genetic data to guide treatment in some situations, and across a variety of therapeutic areas. Clinical implementation of pharmacogenetics has seen substantial growth in recent years and groups are working to identify the barriers and best practices for pharmacogenetic-guided treatment. The advances and challenges in these areas are described and predictions about future use of genetics in drug therapy are discussed.
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Affiliation(s)
- Julie A Johnson
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics, University of Florida, PO Box 100486, Gainesville, FL 32610-0486, USA.
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Sweezy T, Mousa SA. Genotype-guided use of oral antithrombotic therapy: a pharmacoeconomic perspective. Per Med 2014; 11:223-235. [PMID: 29751379 DOI: 10.2217/pme.13.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pharmacogenomics focuses on tailoring therapy to the individual as opposed to the historical model of fitting the individual to the therapy, and it offers the potential to maximize medication efficacy while reducing adverse events. By its very nature, personalized medicine is conducive to a patient-centered care model. Oral antithrombotics as a class could benefit immensely from this type of approach because an imbalance of safety and efficacy in either direction can yield deadly consequences. Since the current healthcare climate in the USA requires thoughtful allocation of resources, pharmacoeconomic analysis has become critical for all stakeholders, and the adoption of new technologies hinges upon economic impact. This article summarizes the current state of genetics in oral antithrombotic therapy, including clinical relevance as well as cost-effectiveness from a US healthcare system perspective, and provides insight into the future of pharmacogenomics in treating and preventing thromboembolic disorders.
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Affiliation(s)
- Taylor Sweezy
- The Pharmaceutical Research Institute, Albany College of Pharmacy & Health Sciences, 1 Discovery Drive, Rensselaer, NY 12144, USA
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy & Health Sciences, 1 Discovery Drive, Rensselaer, NY 12144, USA
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Burt T, Dhillon S. Pharmacogenomics in early-phase clinical development. Pharmacogenomics 2014; 14:1085-97. [PMID: 23837482 DOI: 10.2217/pgs.13.81] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Pharmacogenomics (PGx) offers the promise of utilizing genetic fingerprints to predict individual responses to drugs in terms of safety, efficacy and pharmacokinetics. Early-phase clinical trial PGx applications can identify human genome variations that are meaningful to study design, selection of participants, allocation of resources and clinical research ethics. Results can inform later-phase study design and pipeline developmental decisions. Nevertheless, our review of the clinicaltrials.gov database demonstrates that PGx is rarely used by drug developers. Of the total 323 trials that included PGx as an outcome, 80% have been conducted by academic institutions after initial regulatory approval. Barriers for the application of PGx are discussed. We propose a framework for the role of PGx in early-phase drug development and recommend PGx be universally considered in study design, result interpretation and hypothesis generation for later-phase studies, but PGx results from underpowered studies should not be used by themselves to terminate drug-development programs.
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Affiliation(s)
- Tal Burt
- Duke Global Proof-of-Concept (POC) Research Network, Duke Clinical Research Unit (DCRU) & Duke Clinical Research Institute (DCRI), Duke University, Durham, NC 27710, USA.
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Pirmohamed M, Burnside G, Eriksson N, Jorgensen AL, Toh CH, Nicholson T, Kesteven P, Christersson C, Wahlström B, Stafberg C, Zhang JE, Leathart JB, Kohnke H, Maitland-van der Zee AH, Williamson PR, Daly AK, Avery P, Kamali F, Wadelius M. A randomized trial of genotype-guided dosing of warfarin. N Engl J Med 2013; 369:2294-303. [PMID: 24251363 DOI: 10.1056/nejmoa1311386] [Citation(s) in RCA: 592] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The level of anticoagulation in response to a fixed-dose regimen of warfarin is difficult to predict during the initiation of therapy. We prospectively compared the effect of genotype-guided dosing with that of standard dosing on anticoagulation control in patients starting warfarin therapy. METHODS We conducted a multicenter, randomized, controlled trial involving patients with atrial fibrillation or venous thromboembolism. Genotyping for CYP2C9*2, CYP2C9*3, and VKORC1 (-1639G→A) was performed with the use of a point-of-care test. For patients assigned to the genotype-guided group, warfarin doses were prescribed according to pharmacogenetic-based algorithms for the first 5 days. Patients in the control (standard dosing) group received a 3-day loading-dose regimen. After the initiation period, the treatment of all patients was managed according to routine clinical practice. The primary outcome measure was the percentage of time in the therapeutic range of 2.0 to 3.0 for the international normalized ratio (INR) during the first 12 weeks after warfarin initiation. RESULTS A total of 455 patients were recruited, with 227 randomly assigned to the genotype-guided group and 228 assigned to the control group. The mean percentage of time in the therapeutic range was 67.4% in the genotype-guided group as compared with 60.3% in the control group (adjusted difference, 7.0 percentage points; 95% confidence interval, 3.3 to 10.6; P<0.001). There were significantly fewer incidences of excessive anticoagulation (INR ≥4.0) in the genotype-guided group. The median time to reach a therapeutic INR was 21 days in the genotype-guided group as compared with 29 days in the control group (P<0.001). CONCLUSIONS Pharmacogenetic-based dosing was associated with a higher percentage of time in the therapeutic INR range than was standard dosing during the initiation of warfarin therapy. (Funded by the European Commission Seventh Framework Programme and others; ClinicalTrials.gov number, NCT01119300.).
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Affiliation(s)
- Munir Pirmohamed
- From the University of Liverpool (M.P., G.B., A.L.J., C.H.T., J.E.Z., P.R.W.) and Royal Liverpool and Broadgreen University Hospital National Health Service (NHS) Trust (M.P., C.H.T.), Liverpool, Whiston Hospital, Prescot (T.N.), and Newcastle upon Tyne NHS Trust (P.K.) and Newcastle University (J.B.L., A.K.D., P.A., F.K.), Newcastle upon Tyne - all in the United Kingdom; Uppsala University, Department of Medical Sciences (N.E., C.C., H.K., M.W.), Uppsala Clinical Research Center (N.E.) and Uppsala University Hospital (C.C., B.W., M.W.), Uppsala, and Enköping Hospital, Enköping (C.S.) - all in Sweden; and Utrecht University, Utrecht, the Netherlands (A.H.M.Z.)
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Verhoef TI, Ragia G, de Boer A, Barallon R, Kolovou G, Kolovou V, Konstantinides S, Le Cessie S, Maltezos E, van der Meer FJM, Redekop WK, Remkes M, Rosendaal FR, van Schie RMF, Tavridou A, Tziakas D, Wadelius M, Manolopoulos VG, Maitland-van der Zee AH. A randomized trial of genotype-guided dosing of acenocoumarol and phenprocoumon. N Engl J Med 2013; 369:2304-12. [PMID: 24251360 DOI: 10.1056/nejmoa1311388] [Citation(s) in RCA: 186] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observational evidence suggests that the use of a genotype-guided dosing algorithm may increase the effectiveness and safety of acenocoumarol and phenprocoumon therapy. METHODS We conducted two single-blind, randomized trials comparing a genotype-guided dosing algorithm that included clinical variables and genotyping for CYP2C9 and VKORC1 with a dosing algorithm that included only clinical variables, for the initiation of acenocoumarol or phenprocoumon treatment in patients with atrial fibrillation or venous thromboembolism. The primary outcome was the percentage of time in the target range for the international normalized ratio (INR; target range, 2.0 to 3.0) in the 12-week period after the initiation of therapy. Owing to low enrollment, the two trials were combined for analysis. The primary outcome was assessed in patients who remained in the trial for at least 10 weeks. RESULTS A total of 548 patients were enrolled (273 patients in the genotype-guided group and 275 in the control group). The follow-up was at least 10 weeks for 239 patients in the genotype-guided group and 245 in the control group. The percentage of time in the therapeutic INR range was 61.6% for patients receiving genotype-guided dosing and 60.2% for those receiving clinically guided dosing (P=0.52). There were no significant differences between the two groups for several secondary outcomes. The percentage of time in the therapeutic range during the first 4 weeks after the initiation of treatment in the two groups was 52.8% and 47.5% (P=0.02), respectively. There were no significant differences with respect to the incidence of bleeding or thromboembolic events. CONCLUSIONS Genotype-guided dosing of acenocoumarol or phenprocoumon did not improve the percentage of time in the therapeutic INR range during the 12 weeks after the initiation of therapy. (Funded by the European Commission Seventh Framework Programme and others; EU-PACT ClinicalTrials.gov numbers, NCT01119261 and NCT01119274.).
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Stringer F, DeJongh J, Scott G, Danhof M. A model-based approach to analyze the influence of UGT2B15 polymorphism driven pharmacokinetic differences on the pharmacodynamic response of the PPAR agonist sipoglitazar. J Clin Pharmacol 2013; 54:453-61. [DOI: 10.1002/jcph.227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/04/2013] [Indexed: 11/10/2022]
Affiliation(s)
| | - Joost DeJongh
- LAP&P Consultants BV; Leiden The Netherlands
- Leiden-Amsterdam Centre for Drug Research; Division of Pharmacology; Leiden The Netherlands
| | | | - Meindert Danhof
- LAP&P Consultants BV; Leiden The Netherlands
- Leiden-Amsterdam Centre for Drug Research; Division of Pharmacology; Leiden The Netherlands
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Abstract
Variability in drug responsiveness is a sine qua non of modern therapeutics, and the contribution of genomic variation is increasingly recognized. Investigating the genomic basis for variable responses to cardiovascular therapies has been a model for pharmacogenomics in general and has established critical pathways and specific loci modulating therapeutic responses to commonly used drugs such as clopidogrel, warfarin, and statins. In addition, genomic approaches have defined mechanisms and genetic variants underlying important toxicities with these and other drugs. These findings have not only resulted in changes to the product labels but also have led to development of initial clinical guidelines that consider how to facilitate incorporating genetic information to the bedside. This review summarizes the state of knowledge in cardiovascular pharmacogenomics and considers how variants described to date might be deployed in clinical decision making.
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Abstract
PURPOSE OF REVIEW To review the most promising genetic markers associated with the variability in the safety or efficacy of warfarin and clopidogrel and highlight the verification and validation initiatives for translating clopidogrel and warfarin pharmacogenetic tests to clinical practice. RECENT FINDINGS Rapid advances in pharmacogenetics, continuous decrease in genotyping cost, development of point-of-care devices and the newly established clinical genotyping programs at several institutions hold the promise of individualizing clopidogrel and warfarin based on genotype. Guidelines have been established to assist clinicians in prescribing clopidogrel or warfarin dose based on genotype. However, the clinical utility of clopidogrel and warfarin is still limited. Accordingly, large randomized clinical trials are underway to define the role of clopidogrel and warfarin pharmacogenetics in clinical practice. SUMMARY Pharmacogenetics has offered compelling evidence toward the individualization of clopidogrel and warfarin therapies. The rapid advances in technology make the clinical implementation of clopidogrel and warfarin pharmacogenetics possible. The clinical genotyping programs and the ongoing clinical trials will help in overcoming some of the barriers facing the clinical implementation of clopidogrel and warfarin pharmacogenetics.
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Cost-effectiveness of pharmacogenetics-guided warfarin therapy vs. alternative anticoagulation in atrial fibrillation. Clin Pharmacol Ther 2013; 95:199-207. [PMID: 24067746 DOI: 10.1038/clpt.2013.190] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 09/07/2013] [Indexed: 11/08/2022]
Abstract
Pharmacogenetics-guided warfarin dosing is an alternative to standard clinical algorithms and new oral anticoagulants for patients with nonvalvular atrial fibrillation. However, clinical evidence for pharmacogenetics-guided warfarin dosing is limited to intermediary outcomes, and consequently, there is a lack of information on the cost-effectiveness of anticoagulation treatment options. A clinical trial simulation of S-warfarin was used to predict times within therapeutic range for different dosing algorithms. Relative risks of clinical events, obtained from a meta-analysis of trials linking times within therapeutic range with outcomes, served as inputs to an economic analysis. Neither dabigatran nor rivaroxaban were cost-effective options. Along the cost-effectiveness frontier, in relation to clinically dosed warfarin, pharmacogenetics-guided warfarin and apixaban had incremental cost-effectiveness ratios of £13,226 and £20,671 per quality-adjusted life year gained, respectively. On the basis of our simulations, apixaban appears to be the most cost-effective treatment.
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Kadian-Dodov DL, van der Zee SA, Scott SA, Peter I, Martis S, Doheny DO, Rothlauf EB, Lubitz SA, Desnick RJ, Halperin JL. Warfarin pharmacogenetics: A controlled dose–response study in healthy subjects. Vasc Med 2013; 18:290-7. [DOI: 10.1177/1358863x13503193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The aim of this study was to determine how genetic variants contribute to warfarin dosing variability when non-genetic factors are controlled. Thirty healthy subjects were subjected to a warfarin dosing algorithm with daily international normalized ratio (INR) measurements to INR ≥ 2.0, then off warfarin to INR ≤ 1.2. The primary outcome was the cumulative dose required to achieve INR ≥ 2.0 for 2 consecutive days. CYP2C9 ( p=0.004) and VKORC1 ( p=0.02) variant carriers required lower cumulative doses, and CYP4F2 carriers required higher doses ( p=0.04). Subjects with variants in both CYP2C9 and VKORC1 required fewer days to reach INR ≥ 2.0 than wild-type subjects or those with variants in CYP2C9 or VKORC1 ( p=0.01). Genetic contribution to dose variability (~62%) was greater than previously reported, suggesting that uncontrolled clinical variables influence the effect of these variants. In conclusion, genotype-guided warfarin-dosing algorithms may rely more on genetic variables in healthier individuals than in patients with clinical confounders. ClinicalTrials.gov Identifier: NCT01520402
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Affiliation(s)
- Daniella L Kadian-Dodov
- Vascular Medicine Section, The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stuart A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Inga Peter
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suparna Martis
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dana O Doheny
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth B Rothlauf
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan L Halperin
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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