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Farajzadeh-Dehkordi M, Samiee-Rad F, Farzam SS, Javadi A, Cheraghi S, Hamedi-Asl D, Rahmani B. Evaluation of a warfarin dosing algorithm including CYP2C9, VKORC1, and CYP4F2 polymorphisms and non-genetic determinants for the Iranian population. Pharmacol Rep 2023; 75:695-704. [PMID: 37039974 DOI: 10.1007/s43440-023-00476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The response to warfarin, as an oral anticoagulant agent, varies widely among patients from different ethnic groups. In this study, we tried to ascertain and determine the relationship between non-genetic factors and genetic polymorphisms with warfarin therapy; we then proposed a new warfarin dosing prediction algorithm for the estimation of drug sensitivity and resistance in the Iranian population. METHODS Overall, 200 warfarin-treated patients with stable doses were recruited, the demographic and clinical characteristics were documented, and genotyping was done using a sequencing assay. RESULTS The outcomes of our investigation showed that the genetic polymorphisms of VKORC1(-1639 G > A), CYP2C9*3, CYP2C9*2, amiodarone use, and increasing age were found to be related to a significantly lower mean daily warfarin dose. In contrast, the CYP4F2*3 variant and increased body surface area were linked with an increased dose of warfarin in the Iranians. Our descriptive model could describe 56.5% of the variability in response to warfarin. This population-specific dosing model performed slightly better than other previously published warfarin algorithms for our patient's series. Furthermore, our findings provided the suggestion that incorporating the CYP4F2*3 variant into the dosing algorithm could result in a more precise calculation of warfarin dose requirements in the Iranian population. CONCLUSIONS We proposed and validated a population-specific dosing algorithm based on genetic and non-genetic determinants for Iranian patients and evaluated its performance. Accordingly, by using this newly developed algorithm, prescribers could make more informed decisions regarding the treatment of Iranian patients with warfarin.
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Affiliation(s)
- Mahvash Farajzadeh-Dehkordi
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
- Department of Molecular Medicine, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Fatemeh Samiee-Rad
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
- Department of Pathology, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Seyed Saeed Farzam
- Department of Cardiovascular Surgery, Faculty of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Amir Javadi
- Department of Social Sciences, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Sara Cheraghi
- Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Dariush Hamedi-Asl
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
- Department of Molecular Medicine, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Babak Rahmani
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran.
- Department of Molecular Medicine, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran.
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Asiimwe IG, Pirmohamed M. Ethnic Diversity and Warfarin Pharmacogenomics. Front Pharmacol 2022; 13:866058. [PMID: 35444556 PMCID: PMC9014219 DOI: 10.3389/fphar.2022.866058] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/14/2022] [Indexed: 12/23/2022] Open
Abstract
Warfarin has remained the most commonly prescribed vitamin K oral anticoagulant worldwide since its approval in 1954. Dosing challenges including having a narrow therapeutic window and a wide interpatient variability in dosing requirements have contributed to making it the most studied drug in terms of genotype-phenotype relationships. However, most of these studies have been conducted in Whites or Asians which means the current pharmacogenomics evidence-base does not reflect ethnic diversity. Due to differences in minor allele frequencies of key genetic variants, studies conducted in Whites/Asians may not be applicable to underrepresented populations such as Blacks, Hispanics/Latinos, American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. This may exacerbate health inequalities when Whites/Asians have better anticoagulation profiles due to the existence of validated pharmacogenomic dosing algorithms which fail to perform similarly in the underrepresented populations. To examine the extent to which individual races/ethnicities are represented in the existing body of pharmacogenomic evidence, we review evidence pertaining to published pharmacogenomic dosing algorithms, including clinical utility studies, cost-effectiveness studies and clinical implementation guidelines that have been published in the warfarin field.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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Soltani Banavandi MJ, Satarzadeh N. Association between VKORC1 gene polymorphism and warfarin dose requirement and frequency of VKORC1 gene polymorphism in patients from Kerman province. THE PHARMACOGENOMICS JOURNAL 2020; 20:574-578. [DOI: 10.1038/s41397-019-0146-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 11/10/2019] [Accepted: 12/20/2019] [Indexed: 12/31/2022]
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Prospective validation of the International Warfarin Pharmacogenetics Consortium algorithm in high-risk elderly people (VIALE study). THE PHARMACOGENOMICS JOURNAL 2019; 20:451-461. [DOI: 10.1038/s41397-019-0129-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 11/13/2019] [Accepted: 11/20/2019] [Indexed: 01/10/2023]
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5
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Danese E, Raimondi S, Montagnana M, Tagetti A, Langaee T, Borgiani P, Ciccacci C, Carcas AJ, Borobia AM, Tong HY, Dávila-Fajardo C, Botton MR, Bourgeois S, Deloukas P, Caldwell MD, Burmester JK, Berg RL, Cavallari LH, Drozda K, Huang M, Zhao LZ, Cen HJ, Gonzalez-Conejero R, Roldan V, Nakamura Y, Mushiroda T, Gong IY, Kim RB, Hirai K, Itoh K, Isaza C, Beltrán L, Jiménez-Varo E, Cañadas-Garre M, Giontella A, Kringen MK, Foss Haug KB, Gwak HS, Lee KE, Minuz P, Lee MTM, Lubitz SA, Scott S, Mazzaccara C, Sacchetti L, Genç E, Özer M, Pathare A, Krishnamoorthy R, Paldi A, Siguret V, Loriot MA, Kutala VK, Suarez-Kurtz G, Perini J, Denny JC, Ramirez AH, Mittal B, Rathore SS, Sagreiya H, Altman R, Shahin MHA, Khalifa SI, Limdi NA, Rivers C, Shendre A, Dillon C, Suriapranata IM, Zhou HH, Tan SL, Tatarunas V, Lesauskaite V, Zhang Y, Maitland-van der Zee AH, Verhoef TI, de Boer A, Taljaard M, Zambon CF, Pengo V, Zhang JE, Pirmohamed M, Johnson JA, Fava C. Effect of CYP4F2, VKORC1, and CYP2C9 in Influencing Coumarin Dose: A Single-Patient Data Meta-Analysis in More Than 15,000 Individuals. Clin Pharmacol Ther 2019; 105:1477-1491. [PMID: 30506689 PMCID: PMC6542461 DOI: 10.1002/cpt.1323] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/18/2018] [Indexed: 11/06/2022]
Abstract
The cytochrome P450 (CYP)4F2 gene is known to influence mean coumarin dose. The aim of the present study was to undertake a meta-analysis at the individual patients level to capture the possible effect of ethnicity, gene-gene interaction, or other drugs on the association and to verify if inclusion of CYP4F2*3 variant into dosing algorithms improves the prediction of mean coumarin dose. We asked the authors of our previous meta-analysis (30 articles) and of 38 new articles retrieved by a systematic review to send us individual patients' data. The final collection consists of 15,754 patients split into a derivation and validation cohort. The CYP4F2*3 polymorphism was consistently associated with an increase in mean coumarin dose (+9% (95% confidence interval (CI) 7-10%), with a higher effect in women, in patients taking acenocoumarol, and in white patients. The inclusion of the CYP4F2*3 in dosing algorithms slightly improved the prediction of stable coumarin dose. New pharmacogenetic equations potentially useful for clinical practice were derived.
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Affiliation(s)
- Elisa Danese
- Clinical Biochemistry Section, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Raimondi
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Martina Montagnana
- Clinical Biochemistry Section, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
| | - Angela Tagetti
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Paola Borgiani
- Genetics Section, Department of Biomedicine and Prevention, University of Rome “Tor Vergata,” Rome, Italy
| | - Cinzia Ciccacci
- Genetics Section, Department of Biomedicine and Prevention, University of Rome “Tor Vergata,” Rome, Italy
| | - Antonio J. Carcas
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Alberto M. Borobia
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Hoi Y. Tong
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Cristina Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, IBS, Granada, Spain
| | | | - Stephane Bourgeois
- William Harvey Research Institute, Barts & the London Medical School, Queen Mary University of London, London, UK
| | - Panos Deloukas
- William Harvey Research Institute, Barts & the London Medical School, Queen Mary University of London, London, UK
- Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders (PACER-HD), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Michael D. Caldwell
- Center for Hyperbaric Medicine and Tissue Repair, Marshfield Clinic, Marshfield, Wisconsin, USA
| | - Jim K. Burmester
- Grants Office, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Richard L. Berg
- Clinical Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Katarzyna Drozda
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Li-Zi Zhao
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Han-Jing Cen
- Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Rocio Gonzalez-Conejero
- Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Vanessa Roldan
- Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Yusuke Nakamura
- Research Group for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Taisei Mushiroda
- Research Group for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Inna Y. Gong
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Richard B. Kim
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Keita Hirai
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Carlos Isaza
- Faculty of Heath Sciences, Laboratory of Medical Genetics, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Leonardo Beltrán
- Faculty of Heath Sciences, Laboratory of Medical Genetics, Universidad Tecnológica de Pereira, Pereira, Colombia
- Faculty of Heath Sciences, Unidad Central del Valle del Cauca, Valle del Cauca, Colombia
| | | | - Marisa Cañadas-Garre
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Alice Giontella
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Marianne K. Kringen
- Department of Pharmacology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Kari Bente Foss Haug
- Department of Medical Biochemistry, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Hye Sun Gwak
- Division of Life and Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, Korea
| | - Kyung Eun Lee
- College of Pharmacy, Chungbuk National University, Cheongju-si, Korea
| | - Pietro Minuz
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Ming Ta Michael Lee
- Genomic Medicine Institute, Geisinger Health System, Danville, Pennsylvania, USA
- National Center for Genome Medicine, Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stuart Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina Mazzaccara
- CEINGE–Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Lucia Sacchetti
- CEINGE–Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Ece Genç
- Department of Pharmacology, Yeditepe University, Istanbul, Turkey
| | - Mahmut Özer
- Department of Pharmacology, Yeditepe University, Istanbul, Turkey
| | - Anil Pathare
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | | | - Andras Paldi
- Ecole Pratique des Hautes Etudes, UMRS_951, Genethon, Evry, France
| | - Virginie Siguret
- Sorbonne Paris Cité, INSERM, UMR-S-1140, Université Paris Descartes, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière, Service d’Hématologie Biologique, Paris, France
| | - Marie-Anne Loriot
- Sorbonne Paris Cité, INSERM, UMR-S-1147, Université Paris Descartes, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Biochimie UF Pharmacogénétique et Oncologie Moléculaire, Paris, France
| | - Vijay Kumar Kutala
- Department of Clinical Pharmacology & Therapeutics, Nizam’s Institute of Medical Sciences, Hyderabad, India
| | | | - Jamila Perini
- Research Laboratory of Pharmaceutical Sciences, West Zone State University-UEZO, Rio de Janeiro, Brazil
| | - Josh C. Denny
- Department of Medicine and Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrea H. Ramirez
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Balraj Mittal
- Department of Biotechnology, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | | | - Hersh Sagreiya
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Russ Altman
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Mohamed Hossam A. Shahin
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Sherief I. Khalifa
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Rivers
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aditi Shendre
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, Indiana, USA
| | - Chrisly Dillon
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ivet M. Suriapranata
- Mochtar Riady Institute for Nanotechnology, Universitas Pelita Harapan, Lippo Karawaci, Tangerang, Banten, Indonesia
| | - Hong-Hao Zhou
- Institute of Clinical Pharmacology, Central South University, Hunan Sheng, China
| | - Sheng-Lan Tan
- Department of Pharmacy, Xiangya Second Hospital, Central South University, Hunan Sheng, China
| | - Vacis Tatarunas
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaiva Lesauskaite
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Yumao Zhang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anke H. Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Talitha I. Verhoef
- Department of Applied Health Research, University College London, London, UK
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Monica Taljaard
- Clinica Epidemiology Program and Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Jieying Eunice Zhang
- Wolfson Centre for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Cristiano Fava
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
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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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Pengo V, Denas G. Optimizing quality care for the oral vitamin K antagonists (VKAs). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:332-338. [PMID: 30504329 PMCID: PMC6245991 DOI: 10.1182/asheducation-2018.1.332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Vitamin K antagonists (VKAs) have been the only oral anticoagulants for decades. The management of anticoagulant therapy with VKA is challenging because of the intricate pharmacological properties of these agents. The success of VKA therapy depends on the quality of treatment that is ensured through continuing comprehensive communication and education. The educational program should address important issues of the VKA therapy such as beginning of treatment, pharmacological, dietary, and drug-drug interactions, as well as treatment temporary suspension during surgical interventions or invasive maneuvers. In addition, the initial and continuing patient education is of imperative importance. A major role in the educational process may be addressed by patient associations. The quality of treatment is better reached if patients are followed in anticoagulation clinics. Moreover, a federation of anticoagulation clinics may improve patient care through regular meetings to update knowledge on VKA treatment. Learning objectives of this paper is to allow readers to correctly approach patients starting VKA treatment, recognize possible pitfalls of treatment, and provide adequate solutions.
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Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
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Shendre A, Dillon C, Limdi NA. Pharmacogenetics of warfarin dosing in patients of African and European ancestry. Pharmacogenomics 2018; 19:1357-1371. [PMID: 30345882 PMCID: PMC6562764 DOI: 10.2217/pgs-2018-0146] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/28/2018] [Indexed: 12/20/2022] Open
Abstract
Despite the introduction of direct acting oral anticoagulants, warfarin remains the most commonly prescribed oral anticoagulant. However, warfarin therapy is plagued by the large inter- and intrapatient variability. The variability in dosing fueled research to identify clinical and genetic predictors and develop more accurate dosing algorithms. Observational studies have demonstrated the significant impact of single nucleotide polymorphisms in CYP2C9 and VKORC1 on warfarin dose in patients of European ancestry and African-Americans. This evidence supported the design and conduct of clinical trials to assess whether genotype-guided dosing results in improved anticoagulation control and outcomes. The trial results have shown discordance by race, with pharmacogenetic algorithms improving dose and anticoagulation control among European ancestry patients compared with African-American patients. Herein, we review the evidence from observational and interventional studies, highlight the need for inclusion of minority race groups and propose the need to develop race specific dosing algorithms.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, Richard M Fairbanks School of Public Health, Indiana University Purdue University Indianapolis, IN 46202, USA
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
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Warfarin Dosing According to the Genotype-guided Algorithm is Most Beneficial in Patients With Atrial Fibrillation: A Randomized Parallel Group Trial. Ther Drug Monit 2018; 40:362-368. [DOI: 10.1097/ftd.0000000000000501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Sharabiani A, Nutescu EA, Galanter WL, Darabi H. A New Approach towards Minimizing the Risk of Misdosing Warfarin Initiation Doses. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2018; 2018:5340845. [PMID: 29861781 PMCID: PMC5971298 DOI: 10.1155/2018/5340845] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/07/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
It is a challenge to be able to prescribe the optimal initial dose of warfarin. There have been many studies focused on an efficient strategy to determine the optimal initial dose. Numerous clinical, genetic, and environmental factors affect the warfarin dose response. In practice, it is common that the initial warfarin dose is substantially different from the stable maintenance dose, which may increase the risk of bleeding or thrombosis prior to achieving the stable maintenance dose. In order to minimize the risk of misdosing, despite popular warfarin dose prediction models in the literature which create dose predictions solely based on patients' attributes, we have taken physicians' opinions towards the initial dose into consideration. The initial doses selected by clinicians, along with other standard clinical factors, are used to determine an estimate of the difference between the initial dose and estimated maintenance dose using shrinkage methods. The selected shrinkage method was LASSO (Least Absolute Shrinkage and Selection Operator). The estimated maintenance dose was more accurate than the original initial dose, the dose predicted by a linear model without involving the clinicians initial dose, and the values predicted by the most commonly used model in the literature, the Gage clinical model.
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Affiliation(s)
- Ashkan Sharabiani
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A. Nutescu
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - William L. Galanter
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Houshang Darabi
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
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Zambon CF, Pengo V, Moz S, Bozzato D, Fogar P, Padoan A, Plebani M, Groppa F, De Rosa G, Padrini R. Pharmacokinetic and pharmacodynamic re-evaluation of a genetic-guided warfarin trial. Eur J Clin Pharmacol 2018; 74:571-582. [DOI: 10.1007/s00228-018-2422-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/23/2018] [Indexed: 12/23/2022]
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12
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Li YF, Altman RB. Systematic target function annotation of human transcription factors. BMC Biol 2018; 16:4. [PMID: 29325558 PMCID: PMC5795274 DOI: 10.1186/s12915-017-0469-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 12/06/2017] [Indexed: 01/03/2023] Open
Abstract
Background Transcription factors (TFs), the key players in transcriptional regulation, have attracted great experimental attention, yet the functions of most human TFs remain poorly understood. Recent capabilities in genome-wide protein binding profiling have stimulated systematic studies of the hierarchical organization of human gene regulatory network and DNA-binding specificity of TFs, shedding light on combinatorial gene regulation. We show here that these data also enable a systematic annotation of the biological functions and functional diversity of TFs. Result We compiled a human gene regulatory network for 384 TFs covering the 146,096 TF–target gene (TF–TG) relationships, extracted from over 850 ChIP-seq experiments as well as the literature. By integrating this network of TF–TF and TF–TG relationships with 3715 functional concepts from six sources of gene function annotations, we obtained over 9000 confident functional annotations for 279 TFs. We observe extensive connectivity between TFs and Mendelian diseases, GWAS phenotypes, and pharmacogenetic pathways. Further, we show that TFs link apparently unrelated functions, even when the two functions do not share common genes. Finally, we analyze the pleiotropic functions of TFs and suggest that the increased number of upstream regulators contributes to the functional pleiotropy of TFs. Conclusion Our computational approach is complementary to focused experimental studies on TF functions, and the resulting knowledge can guide experimental design for the discovery of unknown roles of TFs in human disease and drug response. Electronic supplementary material The online version of this article (doi:10.1186/s12915-017-0469-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yong Fuga Li
- Stanford Genome Technology Center, Stanford, CA, USA. .,Department of Bioengineering, Stanford University, Stanford, CA, USA. .,Present address: Department of Bioinformatics, Illumina Inc., San Diego, CA, USA.
| | - Russ B Altman
- Department of Bioengineering, Stanford University, Stanford, CA, USA. .,Department of Genetics, Stanford University, Stanford, CA, USA.
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Colàs-Campàs L, Royo JL, Montserrat MV, Marzo C, Molina-Seguín J, Benabdelhak I, Cambray S, Purroy F. The rs2108622 polymorphism is related to the early risk of ischemic stroke in non-valvular atrial fibrillation subjects under oral anticoagulation. THE PHARMACOGENOMICS JOURNAL 2017; 18:652-656. [PMID: 29273767 DOI: 10.1038/s41397-017-0007-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/30/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
Oral anticoagulant treatments, such as vitamin K antagonists (VKAs), are the main treatments administered to atrial fibrillation (AF) patients in order to prevent ischemic stroke (IS). However, the genes involved in the VKA metabolism can undergo variations in a single nucleotide (SNP). These SNPs may then affect the VKA target enzyme (VKORC1), VKA degradation enzyme (CYP2C9), and vitamin K bioavailability enzyme (CYP4F2). We genotyped these SNPs in a cohort of patients with non-valvular AF who were under VKA treatment after suffering an IS. Clinical variables, CHADS2-VASC score and data about the international normalized ratio (INR) within the therapeutic range were all recorded. DNA was extracted from blood and genotyping was carried out by DNA sequencing. The main endpoint was the time from VKA onset to IS. Of a total of 356 consecutive IS patients monitored, 33 were included in the study. The median time to the event was 2248.0 days (interquartile range [IQR] 896.3-3545.3). The median CHADS2-VASC score was 4.0 (IQR 3.0-6.0). When we considered the risk of IS within 2 years under VKA treatment, we found that only the rs2108622 AA genotype was significantly associated with this endpoint (early IS) (hazard ratio 6.81, 95% CI 1.37-33.92, p = 0.019). Kaplan-Meier curve analysis also showed a significant relationship between early IS and rs2108622 AA genotype (Log rank p = 0.022). The CYP4F2 gene rs2108622 polymorphism was associated with a risk of early IS in NV-AF patients under VKA treatment.
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Affiliation(s)
- L Colàs-Campàs
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). Universitat de Lleida (UdL), Lleida, Spain
| | - J L Royo
- Surgical Specialties, Biochemistry and Immunology Department, Faculty of Medicine, Universidad de Málaga, Malaga, Spain
| | - M V Montserrat
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). Universitat de Lleida (UdL), Lleida, Spain
| | - C Marzo
- Hemostasis Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - J Molina-Seguín
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). Universitat de Lleida (UdL), Lleida, Spain.,Stroke Unit, Clinical Neurosciences Group, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - I Benabdelhak
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). Universitat de Lleida (UdL), Lleida, Spain.,Stroke Unit, Clinical Neurosciences Group, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - S Cambray
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). Universitat de Lleida (UdL), Lleida, Spain
| | - F Purroy
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). Universitat de Lleida (UdL), Lleida, Spain. .,Stroke Unit, Clinical Neurosciences Group, Hospital Universitari Arnau de Vilanova, Lleida, Spain.
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Cerezo-Manchado JJ, Rosafalco M, Antón A, Perez-Andreu V, Garcia-Barberá N, Martínez AB, Corral J, Vicente V, González-Conejero R, Roldán V. Creating a genotype-based dosing algorithm for acenocoumarol steady dose. Thromb Haemost 2017. [DOI: 10.1160/th12-08-0631] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
SummaryAcenocoumarol is a commonly prescribed anticoagulant drug for the prophylaxis and treatment of venous and arterial thromboembolic disorders in several countries. In counterpart of warfarin, there is scarce information about pharmacogenetic algorithms for steady acenocoumarol dose estimation. The aim of this study was to develop an algorithm of prediction for acenocoumarol.The algorithm was created using the data from 973 retrospectively selected anticoagulated patients and was validated in a second independent cohort adding up to 2,683 patients. The best regression model to predict stable dosage in the Primary Cohort included clinical factors (age and body mass index, BSA) and genetic variants (VKORC1, CYP2C9* and CYP4F2 polymorphisms) and explained up to 50% of stable dose. In the validation study the clinical algorithm yielded an adjusted R2=0.15 (estimation´s standard error=4.5) and the genetic approach improved the dose forecast up to 30% (estimation´s standard error=4.6). Again, the best model combined clinical and genetic factors (R2= 0.48; estimation´s standard error=4) which provided the best results of doses estimates within 20% of the real dose in patients taking lower (≤7mg/week) or higher (≥25mg/week) acenocoumarol doses. In conclusion, we developed a prediction algorithm using clinical data and three polymorphisms in VKORC1, CYP2C9* and CYP4F2 genes that provided a steady acenocoumarol dose for about 50% of patients in the Validation Cohort. Such algorithm was especially useful to patients who need higher or lower acenocoumarol doses, those patients with higher time required until their stabilisation and are more prone to suffer a treatment derived complication.
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15
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Jiang Y, Zhao CY, Cheng LC, Xu B, Lv HY. ARLTS1 polymorphism is associated with an increased risk of familial cancer: evidence from a meta-analysis. Hered Cancer Clin Pract 2017. [PMID: 28630657 PMCID: PMC5470195 DOI: 10.1186/s13053-017-0068-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Adenosine diphosphate (ADP)-ribosylation factor-like tumour suppressor gene 1(ARLTS1) might be associated with an increased risk of several types of familial cancers. However, previous studies have shown that cancer susceptibility is not completely consistent with ARLTS1 polymorphisms, and the precise mechanism remains unknown. Therefore, we conducted a meta-analysis of case-control studies by searching the PubMed, Embase, OVID, Science Direct and Chinese National Knowledge Infrastructure (CNKI) databases. In total, 12 studies met the inclusion criteria and were included in this meta-analysis. Statistical analyses were performed using STATA 11.0 software. Overall, the Cys148Arg T > C variant significantly increased cancer risk (CC vs. TT: OR = 1.27, 95% CI = 1.15–1.41, P < 0.05). The stratification indicated that the Cys148Arg variant is significantly associated with sporadic cancer (CC vs. TT: OR = 1.36, 95% CI = 1.18–1.55) and familial cancer (CC vs. TT: OR = 1.26, 95% CI = 1.12–1.43). Trp149Stop, Pro131Leu, Ser99Ser and Leu132Leu were not correlated with cancer susceptibility. Based on these results, we demonstrated that the ARLTS1 Cys148Arg polymorphism is associated with an increased risk of sporadic cancer and familial cancer, and there were no associations between the other four SNPs (i.e., Trp149Stop, Pro131Leu, Ser99Ser and Leu132Leu) and cancer risk.
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Affiliation(s)
- Yan Jiang
- Department of Pharmaceuticals, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116027 People's Republic of China
| | - Chen-Yang Zhao
- Department of Pharmaceuticals, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116027 People's Republic of China
| | - Li-Chun Cheng
- Department of Pharmaceuticals, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116027 People's Republic of China
| | - Bing Xu
- Department of Pharmaceuticals, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116027 People's Republic of China
| | - Hui-Yi Lv
- Department of Pharmaceuticals, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116027 People's Republic of China
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16
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Takeuchi M, Kobayashi T, Brandão LR, Ito S. Effect of CYP2C9, VKORC1, and CYP4F2 polymorphisms on warfarin maintenance dose in children aged less than 18 years: a protocol for systematic review and meta-analysis. Syst Rev 2016; 5:105. [PMID: 27334984 PMCID: PMC4917995 DOI: 10.1186/s13643-016-0280-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/07/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite its shortcomings, warfarin is still the most commonly prescribed anticoagulant to prevent thromboembolism in children. In adults, numerous studies confirmed the robust relationship between warfarin maintenance doses and single nucleotide polymorphisms of cytochrome P450 2C9 (CYP2C9), vitamin K epoxide reductase (VKORC1), and cytochrome P450 4F2 (CYP4F2). However, their effect in children still remains to be determined. The primary objective of the present systematic review and meta-analysis is to assess the effect of genotypes of CYP2C9, VKORC1, and CYP4F2 on warfarin maintenance dose in children. METHODS/DESIGN A comprehensive literature review search using the OVID platform will be conducted by a specialized librarian, without language restrictions (i.e., MEDLINE/EMBASE/Cochrane Central Register of Controlled Trials), and all abstracts will be reviewed by two authors. Data abstraction from each eligible study will be extracted individually by two authors (MT and TK), and disagreements will be resolved through discussion with a third person (SI). Critical appraisal of the included analysis of the primary objective will follow the Newcastle-Ottawa Scale, in addition to the Strengthening the Reporting of Genetic Association study (STREGA) statement, and data reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. For the meta-analysis, the presence vs. absence of each genetic polymorphism will be pursued, respectively, using a random effect model with effect size expressed as a mean difference plus 95 % confidence interval. DISCUSSION Our study will provide a comprehensive systematic review and meta-analysis on the potential effects of CYP2C9, VKORC1, or CYP4F2 on the warfarin maintenance dose in children, exploring the feasibility of the development of pharmacogenetic-guided warfarin dosing algorithm for children on oral vitamin K antagonists. SYSTEMATIC REVIEW REGISTRATION The review has been registered with PROSPERO (registration number CRD42015016172 ).
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Affiliation(s)
- Masanobu Takeuchi
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Tohru Kobayashi
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Leonardo R Brandão
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada.
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17
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Tong HY, Dávila-Fajardo CL, Borobia AM, Martínez-González LJ, Lubomirov R, Perea León LM, Blanco Bañares MJ, Díaz-Villamarín X, Fernández-Capitán C, Cabeza Barrera J, Carcas AJ. A New Pharmacogenetic Algorithm to Predict the Most Appropriate Dosage of Acenocoumarol for Stable Anticoagulation in a Mixed Spanish Population. PLoS One 2016; 11:e0150456. [PMID: 26977927 PMCID: PMC4792430 DOI: 10.1371/journal.pone.0150456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 02/15/2016] [Indexed: 12/25/2022] Open
Abstract
There is a strong association between genetic polymorphisms and the acenocoumarol dosage requirements. Genotyping the polymorphisms involved in the pharmacokinetics and pharmacodynamics of acenocoumarol before starting anticoagulant therapy would result in a better quality of life and a more efficient use of healthcare resources. The objective of this study is to develop a new algorithm that includes clinical and genetic variables to predict the most appropriate acenocoumarol dosage for stable anticoagulation in a wide range of patients. We recruited 685 patients from 2 Spanish hospitals and 1 primary healthcare center. We randomly chose 80% of the patients (n = 556), considering an equitable distribution of genotypes to form the generation cohort. The remaining 20% (n = 129) formed the validation cohort. Multiple linear regression was used to generate the algorithm using the acenocoumarol stable dosage as the dependent variable and the clinical and genotypic variables as the independent variables. The variables included in the algorithm were age, weight, amiodarone use, enzyme inducer status, international normalized ratio target range and the presence of CYP2C9*2 (rs1799853), CYP2C9*3 (rs1057910), VKORC1 (rs9923231) and CYP4F2 (rs2108622). The coefficient of determination (R2) explained by the algorithm was 52.8% in the generation cohort and 64% in the validation cohort. The following R2 values were evaluated by pathology: atrial fibrillation, 57.4%; valve replacement, 56.3%; and venous thromboembolic disease, 51.5%. When the patients were classified into 3 dosage groups according to the stable dosage (<11 mg/week, 11-21 mg/week, >21 mg/week), the percentage of correctly classified patients was higher in the intermediate group, whereas differences between pharmacogenetic and clinical algorithms increased in the extreme dosage groups. Our algorithm could improve acenocoumarol dosage selection for patients who will begin treatment with this drug, especially in extreme-dosage patients. The predictability of the pharmacogenetic algorithm did not vary significantly between diseases.
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Affiliation(s)
- Hoi Y. Tong
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | - Alberto M. Borobia
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
| | - Luis Javier Martínez-González
- Genomics Unit, Centre for Genomics and Oncological Research (GENYO), Pfizer-University of Granada-Andalusian Regional Government, Health Sciences Technology Park, PTS, Granada, Spain
| | - Rubin Lubomirov
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | - Laura María Perea León
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | | | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | - Antonio J. Carcas
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
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18
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Thromboprophylaxis in Patients with Atrial Fibrillation: A Real Practice Analysis. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2016. [DOI: 10.5301/grhta.5000203a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Pengo V, Zambon CF, Fogar P, Padoan A, Nante G, Pelloso M, Moz S, Frigo AC, Groppa F, Bozzato D, Tiso E, Gnatta E, Denas G, Padayattil Jose S, Padrini R, Basso D, Plebani M. A Randomized Trial of Pharmacogenetic Warfarin Dosing in Naïve Patients with Non-Valvular Atrial Fibrillation. PLoS One 2015; 10:e0145318. [PMID: 26710337 PMCID: PMC4692529 DOI: 10.1371/journal.pone.0145318] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 11/30/2015] [Indexed: 01/02/2023] Open
Abstract
UNLABELLED Genotype-guided warfarin dosing have been proposed to improve patient’s management. This study is aimed to determine whether a CYP2C9- VKORC1- CYP4F2-based pharmacogenetic algorithm is superior to a standard, clinically adopted, pharmacodynamic method. Two-hundred naïve patients with non-valvular atrial fibrillation were randomized to trial arms and 180 completed the study. No significant differences were found in the number of out-of-range INRs (INR<2.0 or >3.0) (p = 0.79) and in the mean percentage of time spent in the therapeutic range (TTR) after 19 days in the pharmacogenetic (51.9%) and in the control arm (53.2%, p = 0.71). The percentage of time spent at INR>4.0 was significantly lower in the pharmacogenetic (0.7%) than in the control arm (1.8%) (p = 0.02). Genotype-guided warfarin dosing is not superior in overall anticoagulation control when compared to accurate clinical standard of care. TRIAL REGISTRATION ClinicalTrials.gov NCT01178034.
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Affiliation(s)
- Vittorio Pengo
- Department of Cardiac, Thoracic, and Vascular Sciences University of Padova, Padova, Italy
| | - Carlo-Federico Zambon
- Department of Medicine-DIMED, University of Padova, Padova, Italy
- Department of Laboratory Medicine, University of Padova, Padova, Italy
- * E-mail:
| | - Paola Fogar
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Andrea Padoan
- Department of Medicine-DIMED, University of Padova, Padova, Italy
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Giovanni Nante
- Department of Cardiac, Thoracic, and Vascular Sciences University of Padova, Padova, Italy
| | - Michela Pelloso
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Stefania Moz
- Department of Medicine-DIMED, University of Padova, Padova, Italy
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic, and Vascular Sciences University of Padova, Padova, Italy
| | - Francesca Groppa
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Dania Bozzato
- Department of Medicine-DIMED, University of Padova, Padova, Italy
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Enrico Tiso
- Department of Cardiac, Thoracic, and Vascular Sciences University of Padova, Padova, Italy
| | - Elisa Gnatta
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Gentian Denas
- Department of Cardiac, Thoracic, and Vascular Sciences University of Padova, Padova, Italy
| | - Seena Padayattil Jose
- Department of Cardiac, Thoracic, and Vascular Sciences University of Padova, Padova, Italy
| | - Roberto Padrini
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Daniela Basso
- Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padova, Italy
- Department of Laboratory Medicine, University of Padova, Padova, Italy
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Xu H, Su S, Tang W, Wei M, Wang T, Wang D, Ge W. Comparison of the Performance of the Warfarin Pharmacogenetics Algorithms in Patients with Surgery of Heart Valve Replacement and Heart Valvuloplasty. Thromb Res 2015; 136:552-9. [DOI: 10.1016/j.thromres.2015.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/12/2015] [Accepted: 06/30/2015] [Indexed: 12/14/2022]
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22
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Revisiting Warfarin Dosing Using Machine Learning Techniques. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:560108. [PMID: 26146514 PMCID: PMC4471424 DOI: 10.1155/2015/560108] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/11/2015] [Accepted: 05/21/2015] [Indexed: 12/23/2022]
Abstract
Determining the appropriate dosage of warfarin is an important yet challenging task. Several prediction models have been proposed to estimate a therapeutic dose for patients. The models are either clinical models which contain clinical and demographic variables or pharmacogenetic models which additionally contain the genetic variables. In this paper, a new methodology for warfarin dosing is proposed. The patients are initially classified into two classes. The first class contains patients who require doses of >30 mg/wk and the second class contains patients who require doses of ≤30 mg/wk. This phase is performed using relevance vector machines. In the second phase, the optimal dose for each patient is predicted by two clinical regression models that are customized for each class of patients. The prediction accuracy of the model was 11.6 in terms of root mean squared error (RMSE) and 8.4 in terms of mean absolute error (MAE). This was 15% and 5% lower than IWPC and Gage models (which are the most widely used models in practice), respectively, in terms of RMSE. In addition, the proposed model was compared with fixed-dose approach of 35 mg/wk, and the model proposed by Sharabiani et al. and its outperformance were proved in terms of both MAE and RMSE.
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23
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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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24
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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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25
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Haas DM. Pharmacogenetics and individualizing drug treatment during pregnancy. Pharmacogenomics 2014; 15:69-78. [PMID: 24329192 DOI: 10.2217/pgs.13.228] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Pharmacogenetics as a tool to aid clinicians implement individualized pharmacotherapy is utilized in some areas of medicine. Pharmacogenetics in pregnancy is still a developing field. However, there are several areas of obstetric therapeutics where data are emerging that give glimpses into future therapeutic possibilities. These include opioid pain management, antihypertensive therapy, antidepressant medications, preterm labor tocolytics, antenatal corticosteroids and drugs for nausea and vomiting of pregnancy, to name a few. More data are needed to populate the therapeutic models and to truly determine if pharmacogenetics will aid in individualizing pharmacotherapy in pregnancy. The objective of this review is to summarize current data and highlight research needs.
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Affiliation(s)
- David M Haas
- Department of OB/GYN, Indiana University School of Medicine, 1001 W. 10th Street, F5102, Indianapolis, IN 46202, USA.
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Grossi E, Podda GM, Pugliano M, Gabba S, Verri A, Carpani G, Buscema M, Casazza G, Cattaneo M. Prediction of optimal warfarin maintenance dose using advanced artificial neural networks. Pharmacogenomics 2014; 15:29-37. [PMID: 24329188 DOI: 10.2217/pgs.13.212] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In recent years, pharmacogenetic algorithms were developed for estimating the appropriate dose of vitamin K antagonists. AIM To evaluate the performance of new generation artificial neural networks (ANNs) to predict the warfarin maintenance dose. METHODS Demographic, clinical and genetic data (CYP2C9 and VKORC1 polymorphisms) from 377 patients treated with warfarin were used. The final prediction model was based on 23 variables selected by TWIST® system within a bipartite division of the data set (training and testing) protocol. RESULTS The ANN algorithm reached high accuracy, with an average absolute error of 5.7 mg of the warfarin maintenance dose. In the subset of patients requiring ≤21 mg and 21-49 mg (45 and 51% of the cohort, respectively) the absolute error was 3.86 mg and 5.45 with a high percentage of subjects being correctly identified (71 and 73%, respectively). CONCLUSION ANN appears to be a promising tool for vitamin K antagonist maintenance dose prediction.
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Mazzaccara C, Conti V, Liguori R, Simeon V, Toriello M, Severini A, Perricone C, Meccariello A, Meccariello P, Vitale DF, Filippelli A, Sacchetti L. Warfarin anticoagulant therapy: a Southern Italy pharmacogenetics-based dosing model. PLoS One 2013; 8:e71505. [PMID: 23990957 PMCID: PMC3753327 DOI: 10.1371/journal.pone.0071505] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 06/30/2013] [Indexed: 12/20/2022] Open
Abstract
Background and Aim Warfarin is the most frequently prescribed anticoagulant worldwide. However, warfarin therapy is associated with a high risk of bleeding and thromboembolic events because of a large interindividual dose-response variability. We investigated the effect of genetic and non genetic factors on warfarin dosage in a South Italian population in the attempt to setup an algorithm easily applicable in the clinical practice. Materials and Methods A total of 266 patients from Southern Italy affected by cardiovascular diseases were enrolled and their clinical and anamnestic data recorded. All patients were genotyped for CYP2C9*2,*3, CYP4F2*3, VKORC1 -1639 G>A by the TaqMan assay and for variants VKORC1 1173 C>T and VKORC1 3730 G>A by denaturing high performance liquid chromatography and direct sequencing. The effect of genetic and not genetic factors on warfarin dose variability was tested by multiple linear regression analysis, and an algorithm based on our data was established and then validated by the Jackknife procedure. Results Warfarin dose variability was influenced, in decreasing order, by VKORC1-1639 G>A (29.7%), CYP2C9*3 (11.8%), age (8.5%), CYP2C9*2 (3.5%), gender (2.0%) and lastly CYP4F2*3 (1.7%); VKORC1 1173 C>T and VKORC1 3730 G>A exerted a slight effect (<1% each). Taken together, these factors accounted for 58.4% of the warfarin dose variability in our population. Data obtained with our algorithm significantly correlated with those predicted by the two online algorithms: Warfarin dosing and Pharmgkb (p<0.001; R2 = 0.805 and p<0.001; R2 = 0.773, respectively). Conclusions Our algorithm, which is based on six polymorphisms, age and gender, is user-friendly and its application in clinical practice could improve the personalized management of patients undergoing warfarin therapy.
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Affiliation(s)
- Cristina Mazzaccara
- CEINGE– Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Valeria Conti
- Dipartimento di Medicina e Chirurgia, Università di Salerno, Salerno, Italy
| | - Rosario Liguori
- CEINGE– Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Vittorio Simeon
- Laboratorio di Ricerca Pre-clinica e Traslazionale Oncologica, Centro di Riferimento Oncologico della Basilicata, Istituto di Ricovero e Cura a Carattere Scientifico, Rionero in Vulture (Pz), Italy
| | - Mario Toriello
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Angelo Severini
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | | | - Alfonso Meccariello
- Dipartimento di Medicina Interna, Università of Napoli Federico II, Napoli, Italy
| | - Pasquale Meccariello
- Dipartimento di Medicina Interna, Università of Napoli Federico II, Napoli, Italy
| | - Dino Franco Vitale
- Fondazione Salvatore Maugeri, IRCCS Istituto di Campoli Telese, Benevento, Italy
| | - Amelia Filippelli
- Dipartimento di Medicina e Chirurgia, Università di Salerno, Salerno, Italy
| | - Lucia Sacchetti
- CEINGE– Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
- * E-mail:
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Pengo V. Laboratory tests during direct oral anticoagulant treatment? Yes. Intern Emerg Med 2013; 8:371-2. [PMID: 23686690 DOI: 10.1007/s11739-013-0949-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 04/20/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Vittorio Pengo
- Clinical Cardiology, Department of Cardiac Thoracic and Vascular Sciences, University of Padova, Padua, Italy,
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Pharmacogenetics and other reasons why drugs can fail in pregnancy: higher dose or different drug? Obstet Gynecol 2013; 120:1176-9. [PMID: 23090536 DOI: 10.1097/aog.0b013e3182698538] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Changes in maternal physiology during pregnancy can alter the absorption, distribution, and clearance of many drugs. When presented with a clinical situation in which it does not appear that a prescribed drug is working, clinicians must either change drugs or increase the dose of the current drug to achieve the desired clinical effect. A case highlighting antihypertensive medication in pregnancy and the effect of changed drug-metabolizing enzymes is presented. Understanding pregnancy's effect on drug-metabolizing enzymes, transporters, and receptors can help clinicians make individualized pharmacotherapeutic decisions for patients. Pharmacogenetics potentially can aid clinicians in treating pregnant women in the future as more data are generated and individualized therapeutic models are constructed.
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Ohno I, Araki T, Kawano M, Nakamura T, Yamamoto K. SENSITIVE AND SIMPLE DETERMINATION OF VITAMIN K1 IN HUMAN PLASMA BY ULTRA-PERFORMANCE LIQUID CHROMATOGRAPHY COUPLED WITH A FLUORESCENCE DETECTOR. J LIQ CHROMATOGR R T 2013. [DOI: 10.1080/10826076.2012.685908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Izumi Ohno
- a Department of Clinical Pharmacology , Gunma University Graduate School of Medicine , Maebashi , Japan
- b Department of Pharmacy , Gunma University Hospital , Maebashi , Japan
| | - Takuya Araki
- a Department of Clinical Pharmacology , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Masashi Kawano
- a Department of Clinical Pharmacology , Gunma University Graduate School of Medicine , Maebashi , Japan
| | - Tomonori Nakamura
- a Department of Clinical Pharmacology , Gunma University Graduate School of Medicine , Maebashi , Japan
- b Department of Pharmacy , Gunma University Hospital , Maebashi , Japan
| | - Koujirou Yamamoto
- a Department of Clinical Pharmacology , Gunma University Graduate School of Medicine , Maebashi , Japan
- b Department of Pharmacy , Gunma University Hospital , Maebashi , Japan
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Shah RR, Shah DR. Personalized medicine: is it a pharmacogenetic mirage? Br J Clin Pharmacol 2013; 74:698-721. [PMID: 22591598 DOI: 10.1111/j.1365-2125.2012.04328.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The notion of personalized medicine has developed from the application of the discipline of pharmacogenetics to clinical medicine. Although the clinical relevance of genetically-determined inter-individual differences in pharmacokinetics is poorly understood, and the genotype-phenotype association data on clinical outcomes often inconsistent, officially approved drug labels frequently include pharmacogenetic information concerning the safety and/or efficacy of a number of drugs and refer to the availability of the pharmacogenetic test concerned. Regulatory authorities differ in their approach to these issues. Evidence emerging subsequently has generally revealed the pharmacogenetic information included in the label to be premature. Revised drugs labels, together with a flurry of other collateral activities, have raised public expectations of personalized medicine, promoted as 'the right drug at the right dose the first time.' These expectations place the prescribing physician in a dilemma and at risk of litigation, especially when evidence-based information on genotype-related dosing schedules is to all intent and purposes non-existent and guidelines, intended to improve the clinical utility of available pharmacogenetic information or tests, distance themselves from any responsibility. Lack of efficacy or an adverse drug reaction is frequently related to non-genetic factors. Phenoconversion, arising from drug interactions, poses another often neglected challenge to any potential success of personalized medicine by mimicking genetically-determined enzyme deficiency. A more realistic promotion of personalized medicine should acknowledge current limitations and emphasize that pharmacogenetic testing can only improve the likelihood of diminishing a specific toxic effect or increasing the likelihood of a beneficial effect and that application of pharmacogenetics to clinical medicine cannot adequately predict drug response in individual patients.
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Fusaro VA, Patil P, Chi CL, Contant CF, Tonellato PJ. A systems approach to designing effective clinical trials using simulations. Circulation 2012; 127:517-26. [PMID: 23261867 DOI: 10.1161/circulationaha.112.123034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pharmacogenetics in warfarin clinical trials have failed to show a significant benefit in comparison with standard clinical therapy. This study demonstrates a computational framework to systematically evaluate preclinical trial design of target population, pharmacogenetic algorithms, and dosing protocols to optimize primary outcomes. METHODS AND RESULTS We programmatically created an end-to-end framework that systematically evaluates warfarin clinical trial designs. The framework includes options to create a patient population, multiple dosing strategies including genetic-based and nongenetic clinical-based, multiple-dose adjustment protocols, pharmacokinetic/pharmacodynamics modeling and international normalization ratio prediction, and various types of outcome measures. We validated the framework by conducting 1000 simulations of the applying pharmacogenetic algorithms to individualize dosing of warfarin (CoumaGen) clinical trial primary end points. The simulation predicted a mean time in therapeutic range of 70.6% and 72.2% (P=0.47) in the standard and pharmacogenetic arms, respectively. Then, we evaluated another dosing protocol under the same original conditions and found a significant difference in the time in therapeutic range between the pharmacogenetic and standard arm (78.8% versus 73.8%; P=0.0065), respectively. CONCLUSIONS We demonstrate that this simulation framework is useful in the preclinical assessment phase to study and evaluate design options and provide evidence to optimize the clinical trial for patient efficacy and reduced risk.
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Affiliation(s)
- Vincent A Fusaro
- Center for Biomedical Informatics Harvard Medical School, 10 Shattuck Street, Boston, MA 02115, USA
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Carcas AJ, Borobia AM, Velasco M, Abad-Santos F, Díaz MQ, Fernández-Capitán C, Ruiz-Giménez N, Madridano O, Sillero PL. Efficiency and effectiveness of the use of an acenocoumarol pharmacogenetic dosing algorithm versus usual care in patients with venous thromboembolic disease initiating oral anticoagulation: study protocol for a randomized controlled trial. Trials 2012; 13:239. [PMID: 23237631 PMCID: PMC3543328 DOI: 10.1186/1745-6215-13-239] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 11/08/2012] [Indexed: 12/13/2022] Open
Abstract
Background Hemorrhagic events are frequent in patients on treatment with antivitamin-K oral anticoagulants due to their narrow therapeutic margin. Studies performed with acenocoumarol have shown the relationship between demographic, clinical and genotypic variants and the response to these drugs. Once the influence of these genetic and clinical factors on the dose of acenocoumarol needed to maintain a stable international normalized ratio (INR) has been demonstrated, new strategies need to be developed to predict the appropriate doses of this drug. Several pharmacogenetic algorithms have been developed for warfarin, but only three have been developed for acenocoumarol. After the development of a pharmacogenetic algorithm, the obvious next step is to demonstrate its effectiveness and utility by means of a randomized controlled trial. The aim of this study is to evaluate the effectiveness and efficiency of an acenocoumarol dosing algorithm developed by our group which includes demographic, clinical and pharmacogenetic variables (VKORC1, CYP2C9, CYP4F2 and ApoE) in patients with venous thromboembolism (VTE). Methods and design This is a multicenter, single blind, randomized controlled clinical trial. The protocol has been approved by La Paz University Hospital Research Ethics Committee and by the Spanish Drug Agency. Two hundred and forty patients with VTE in which oral anticoagulant therapy is indicated will be included. Randomization (case/control 1:1) will be stratified by center. Acenocoumarol dose in the control group will be scheduled and adjusted following common clinical practice; in the experimental arm dosing will be following an individualized algorithm developed and validated by our group. Patients will be followed for three months. The main endpoints are: 1) Percentage of patients with INR within the therapeutic range on day seven after initiation of oral anticoagulant therapy; 2) Time from the start of oral anticoagulant treatment to achievement of a stable INR within the therapeutic range; 3) Number of INR determinations within the therapeutic range in the first six weeks of treatment. Discussion To date, there are no clinical trials comparing pharmacogenetic acenocoumarol dosing algorithm versus routine clinical practice in VTE. Implementation of this pharmacogenetic algorithm in the clinical practice routine could reduce side effects and improve patient safety. Trial registration Eudra CT. Identifier: 2009-016643-18.
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Affiliation(s)
- Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain.
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Impact of the CYP4F2 p.V433M polymorphism on coumarin dose requirement: systematic review and meta-analysis. Clin Pharmacol Ther 2012; 92:746-56. [PMID: 23132553 DOI: 10.1038/clpt.2012.184] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A systematic review and a meta-analysis were performed to quantify the accumulated information from genetic association studies investigating the impact of the CYP4F2 rs2108622 (p.V433M) polymorphism on coumarin dose requirement. An additional aim was to explore the contribution of the CYP4F2 variant in comparison with, as well as after stratification for, the VKORC1 and CYP2C9 variants. Thirty studies involving 9,470 participants met prespecified inclusion criteria. As compared with CC-homozygotes, T-allele carriers required an 8.3% (95% confidence interval (CI): 5.6-11.1%; P < 0.0001) higher mean daily coumarin dose than CC homozygotes to reach a stable international normalized ratio (INR). There was no evidence of publication bias. Heterogeneity among studies was present (I(2) = 43%). Our results show that the CYP4F2 p.V433M polymorphism is associated with interindividual variability in response to coumarin drugs, but with a low effect size that is confirmed to be lower than those contributed by VKORC1 and CYP2C9 polymorphisms.
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The prevalence of VKORC1 1639 G>A and CYP2C9*2*3 genotypes in patients that requiring anticoagulant therapy in Turkish population. Mol Biol Rep 2012; 39:11017-22. [PMID: 23065265 DOI: 10.1007/s11033-012-2004-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 10/01/2012] [Indexed: 12/28/2022]
Abstract
The aim was to investigate the prevalence of VKORC1 and CYP2C9 genotypes in patients requiring anticoagulant therapy in two different region's populations of Turkey. The recent cohort included 292 patients that needed anticoagulant therapy, and who had a history of deep vein thrombosis and/or pulmonary artery thromboembolism. Genomic DNA was isolated from peripheral blood samples and the StripAssay reverse hybridization or Real Time PCR technique was used for genotype analysis. Genotypes for CYP2C9 were detected as follows: 165 (56.5 %) for CYP2C9*1/*1, 67 (23.0 %) for CYP2C9*1/*2, 25 (8.6 %) for CYP2C9*1/*3, 9 (3.0 %) for CYP2C9*2/*2, 21 (7.2 %) for CYP2C9*2/*3, 5(1.7 %) for CYP2C9*3/*3 for CYP2C9 and the allele frequencies were: 0.723 for allele*1, 0.182 for allele*2 and 0.095 for allele*3 respectively. Genotypes for VKORC1 were detected as follows: 64 (21.9 %) for GG, 220 (75.4 %) for GA and 8 (2.7 %) for AA alleles. The G allele frequency was detected as 0.596, and the A allele frequency was 0.404. The VKORC1 1639 G>A and CYP2C9 mutation prevalence and allele frequency of the current results from two different populations (Sivas and Canakkale) showed similarly very variable profiles when compared to the other results from the Turkish population.
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Liu Y, Yang J, Xu Q, Xu B, Gao L, Zhang Y, Zhang Y, Wang H, Lu C, Zhao Y, Yin T. Comparative performance of warfarin pharmacogenetic algorithms in Chinese patients. Thromb Res 2012; 130:435-40. [DOI: 10.1016/j.thromres.2012.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/17/2012] [Accepted: 02/06/2012] [Indexed: 01/28/2023]
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Borobia AM, Lubomirov R, Ramírez E, Lorenzo A, Campos A, Muñoz-Romo R, Fernández-Capitán C, Frías J, Carcas AJ. An acenocoumarol dosing algorithm using clinical and pharmacogenetic data in Spanish patients with thromboembolic disease. PLoS One 2012; 7:e41360. [PMID: 22911785 PMCID: PMC3401172 DOI: 10.1371/journal.pone.0041360] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 06/20/2012] [Indexed: 12/13/2022] Open
Abstract
Appropriate dosing of coumarins is difficult to establish, due to significant inter-individual variability in the dose required to obtain stable anticoagulation. Several genetic and other clinical factors have been associated with the coumarins dose, and some pharmacogenetic-guided dosing algorithms for warfarin and acenocoumarol have been developed for mixed populations. We recruited 147 patients with thromboembolic disease who were on stable doses and with an international normalized ratio (INR) between 2 and 3. We ascertained the influence of clinical and genetic variables on the stable acenocoumarol dose by multiple linear regression analysis in a derivation cohort (DC; n = 117) and developed an algorithm for dosing that included clinical factors (age, body mass index and concomitant drugs) and genetic variations of VKORC1, CYP2C9, CYP4F2 and APOE. For purposes of comparison, a model including only clinical data was created. The clinical factors explained 22% of the dose variability, which increased to 60.6% when pharmacogenetic information was included (p<0.001); CYP4F2 and APOE variants explained 4.9% of this variability. The mean absolute error of the predicted acenocoumarol dose (mg/week) obtained with the pharmacogenetic algorithm was 3.63 vs. 5.08 mg/week with the clinical algorithm (95% CI: 0.88 to 2.04). In the testing cohort (n = 30), clinical factors explained a mere 7% of the dose variability, compared to 39% explained by the pharmacogenetic algorithm. Considering a more clinically relevant parameter, the pharmacogenetic algorithm correctly predicted the real stable dose in 59.8% of the cases (DC) vs. only 37.6% predicted by the clinical algorithm (95% CI: 10 to 35). Therefore the number of patients needed to genotype to avoid one over- or under-dosing was estimated to be 5.
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Affiliation(s)
- Alberto M. Borobia
- Clinical Pharmacology Service, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
| | - Rubin Lubomirov
- Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology Service, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
| | - Alicia Lorenzo
- Internal Medicine Department, La Paz University Hospital, Madrid, Spain
| | - Armando Campos
- Clinical Pharmacology Service, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Raul Muñoz-Romo
- Clinical Pharmacology Service, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carmen Fernández-Capitán
- Internal Medicine Department, La Paz University Hospital, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Jesús Frías
- Clinical Pharmacology Service, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
| | - Antonio J. Carcas
- Clinical Pharmacology Service, La Paz University Hospital, Pharmacology Department, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
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Impact of CYP2C9*3, VKORC1-1639, CYP4F2rs2108622 genetic polymorphism and clinical factors on warfarin maintenance dose in Han-Chinese patients. J Thromb Thrombolysis 2012; 34:120-5. [DOI: 10.1007/s11239-012-0725-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Smires FZ, Moreau C, Habbal R, Siguret V, Fadili S, Golmard JL, Assaidi A, Beaune P, Loriot MA, Nadifi S. Influence of genetics and non-genetic factors on acenocoumarol maintenance dose requirement in Moroccan patients. J Clin Pharm Ther 2012; 37:594-8. [PMID: 22486182 DOI: 10.1111/j.1365-2710.2012.01340.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Coumarin derivatives such as acenocoumarol represent the therapy of choice for the long-term treatment and prevention of thromboembolic diseases. Many genetic, clinical and demographic factors have been shown to influence the anticoagulant dosage. Our aim was to investigate the contribution of genetic and non-genetic factors to variability in response to acenocoumarol in Moroccan patients. METHODS Our study included 114 adult Moroccan patients, receiving long-term acenocoumarol therapy for various indications. Tests for VKORC1 -1639G>A promoter polymorphism (rs9923231), CYP2C9*2 rs1799853, CYP2C9*3 rs1057910, and CYP4F2 rs2108622 alleles were undertaken using Taq Man(®) Pre-Developed Assay Reagents for allelic discrimination. The statistical analysis was performed using the SAS V9 statistical package. RESULTS AND DISCUSSION Genotyping showed that the allele frequencies for the SNPs studied were no different to those found in Caucasians population. A significant association was observed between the weekly maintenance dose and the VKORC1 (P = 0·0027) and CYP2C9 variant genotypes (P = 0·0082). A final multivariate regression model that included the target International Normalized Ratio, VKORC1 and CYP2C9 genotypes explained 36·2% of the overall interindividual variability in acenocoumarol dose requirement. WHAT IS NEW AND CONCLUSION Our study shows large interindividual variability in acenocoumarol maintenance dose requirement in our population. VKORC1 and CYP2C9 variants significantly affected acenocoumarol dose, in-line with results in other populations. For the Moroccan population, the SNPs that have the largest effect on acecoumarol dose are CYP2C9 rs1799853, CYP2C9 rs1057910 and VKORC1 rs9923231.
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Affiliation(s)
- F Z Smires
- Medical Genetic Laboratory and Molecular Pathology, Medical School, Casablanca, Morocco.
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Cavallari LH, Shin J, Perera MA. Role of pharmacogenomics in the management of traditional and novel oral anticoagulants. Pharmacotherapy 2012; 31:1192-207. [PMID: 22122181 DOI: 10.1592/phco.31.12.1192] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Warfarin is the most commonly prescribed oral anticoagulant. However, it remains a difficult drug to manage mostly because of its narrow therapeutic index and wide interpatient variability in anticoagulant effects. Over the past decade, there has been substantial progress in our understanding of genetic contributions to variable warfarin response, particularly with regard to warfarin dose requirements. The genes encoding for cytochrome P450 (CYP) 2C9 (CYP2C9) and vitamin K epoxide reductase complex subunit 1 (VKORC1) are the major genetic determinants of warfarin pharmacokinetics and pharmacodynamics, respectively. Numerous studies have demonstrated significant contributions of these genes to warfarin dose requirements. The CYP2C9 gene has also been associated with bleeding risk with warfarin. The CYP4F2 gene influences vitamin K availability and makes minor contributions to warfarin dose requirements. Less is known about genes influencing warfarin response in African-American patients compared with other racial groups, but this is the focus of ongoing research. Several warfarin pharmacogenetic dosing algorithms and United States Food and Drug Administration-cleared genotyping tests are available for clinical use. Clinical trials are ongoing to determine the clinical utility and cost-effectiveness of genotypeguided warfarin dosing. Results from these trials will likely influence clinical uptake and third party payer reimbursement for genotype-guided warfarin therapy. There is still a lack of pharmacogenetic data for the newly approved oral anticoagulants, dabigatran and rivaroxaban, and with other oral anticoagulants in the research and development pipeline. These data, once known, could be of great importance as routine monitoring parameters for these agents are not available.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois 60612-7230, USA.
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Kasarskis A, Yang X, Schadt E. Integrative genomics strategies to elucidate the complexity of drug response. Pharmacogenomics 2012; 12:1695-715. [PMID: 22118053 DOI: 10.2217/pgs.11.115] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pharmacogenomic investigation from both genome-wide association studies and experiments focused on candidate loci involved in drug mechanism and metabolism has yielded a substantial and increasing list of robust genetic effects on drug therapy in humans. At the same time, reasonably comprehensive molecular data such as gene expression, proteomic and metabolomic data are now available for collections of hundreds to thousands of individuals. If these data are structured in a statistically robust and computationally tractable way, such as a network model, they can aid in the analysis of new pharmacogenomics studies by suggesting novel hypotheses for the regulation of genes involved in drug metabolism and response. Similarly, hypotheses taken from these same models can direct genome-wide association studies by focusing the genome-wide association studies analysis on a number of specific hypotheses informed by the relationships customarily seen between a gene's expression or protein activity and genetic variation at a particular locus. Network models based on other sorts of systematic biological data such as cell-based surveys of drug effect on gene expression and mining of literature and electronic medical records for associations between clinical and molecular phenotypes also promise similar utility. Although surely primitive in comparison with what will be developed, these model-based approaches to leveraging the increasing volume of data generated in the course of patient care and medical research nevertheless suggest a huge opportunity to improve our understanding of biological systems involved in pharmacogenomics and apply them to questions of medical relevance.
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A new warfarin dosing algorithm including VKORC1 3730 G > A polymorphism: comparison with results obtained by other published algorithms. Eur J Clin Pharmacol 2012; 68:1167-74. [DOI: 10.1007/s00228-012-1226-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 01/14/2012] [Indexed: 11/27/2022]
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Ramirez AH, Shi Y, Schildcrout JS, Delaney JT, Xu H, Oetjens MT, Zuvich RL, Basford MA, Bowton E, Jiang M, Speltz P, Zink R, Cowan J, Pulley JM, Ritchie MD, Masys DR, Roden DM, Crawford DC, Denny JC. Predicting warfarin dosage in European-Americans and African-Americans using DNA samples linked to an electronic health record. Pharmacogenomics 2012; 13:407-18. [PMID: 22329724 DOI: 10.2217/pgs.11.164] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIM Warfarin pharmacogenomic algorithms reduce dosing error, but perform poorly in non-European-Americans. Electronic health record (EHR) systems linked to biobanks may allow for pharmacogenomic analysis, but they have not yet been used for this purpose. PATIENTS & METHODS We used BioVU, the Vanderbilt EHR-linked DNA repository, to identify European-Americans (n = 1022) and African-Americans (n = 145) on stable warfarin therapy and evaluated the effect of 15 pharmacogenetic variants on stable warfarin dose. RESULTS Associations between variants in VKORC1, CYP2C9 and CYP4F2 with weekly dose were observed in European-Americans as well as additional variants in CYP2C9 and CALU in African-Americans. Compared with traditional 5 mg/day dosing, implementing the US FDA recommendations or the International Warfarin Pharmacogenomics Consortium (IWPC) algorithm reduced error in weekly dose in European-Americans (13.5-12.4 and 9.5 mg/week, respectively) but less so in African-Americans (15.2-15.0 and 13.8 mg/week, respectively). By further incorporating associated variants specific for European-Americans and African-Americans in an expanded algorithm, dose-prediction error reduced to 9.1 mg/week (95% CI: 8.4-9.6) in European-Americans and 12.4 mg/week (95% CI: 10.0-13.2) in African-Americans. The expanded algorithm explained 41 and 53% of dose variation in African-Americans and European-Americans, respectively, compared with 29 and 50%, respectively, for the IWPC algorithm. Implementing these predictions via dispensable pill regimens similarly reduced dosing error. CONCLUSION These results validate EHR-linked DNA biorepositories as real-world resources for pharmacogenomic validation and discovery.
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Affiliation(s)
- Andrea H Ramirez
- Department of Medicine, Vanderbilt University in Nashville, TN 37232, USA
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Intérêt clinique de la pharmacogénétique : anticiper les toxicités et mieux prédire l’efficacité des médicaments. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0336-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Liang R, Wang C, Zhao H, Huang J, Hu D, Sun Y. Influence of CYP4F2 genotype on warfarin dose requirement-a systematic review and meta-analysis. Thromb Res 2011; 130:38-44. [PMID: 22192158 DOI: 10.1016/j.thromres.2011.11.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/30/2011] [Accepted: 11/24/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Warfarin is a commonly used oral anticoagulant and the dosage is individually adjusted on the basis of the international normalized ratio (INR) monitoring. It is well known that gene polymorphisms of CytochromeP450 (CYP) 2C9 gene and the vitamin K epoxide reductase complex 1 (VKORC1) were significantly associated with warfarin dose. However, the association between Cytochrome P450 4F2 (CYP4F2) polymorphism and warfarin dose requirement is still controversial. This study was to investigate the influence of the CYP4F2 polymorphism, V433M (rs2108622) on warfarin dose for patients by meta-analysis. METHODS Strict inclusion and exclusion criteria were set, and the studies prior to December 19, 2010 were searched in PubMed, EMBASE and CNKI. References were examined and experts of primary studies were consulted for additional information. Revman 5.0.2 software was used to analyze the relationship between warfarin maintenance dose and CYP4F2 polymorphism RESULTS Thirteen studies were included in the meta-analysis which consisted of Caucasian, Asian and African populations. Compared to individuals with the homozygous CYP4F2 genotype (CC), carriers of CT, TT genotypes required 10.0% (95% confidence interval(CI) 4.0-15.0) and 21.0% (95% CI 9.0-33.0) higher warfarin doses respectively (P value <0.05). In addition, T carriers required 11.0% (95% CI 6.0-17.0) higher warfarin dose than CC genotype. CONCLUSIONS Our study showed that polymorphism of CYP4F2 had a moderate but statistically significant association with the variation of interindividual warfarin dose. However, whether CYP4F2 can improve the prediction of warfarin dose warrants need further investigation when combined with environmental factors.
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Affiliation(s)
- Ruijuan Liang
- Heart Center, Peking University People's Hospital, Beijing, China
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Vitamin K antagonists in children with heart disease: height and VKORC1 genotype are the main determinants of the warfarin dose requirement. Blood 2011; 119:861-7. [PMID: 22130800 DOI: 10.1182/blood-2011-07-365502] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Managing vitamin K antagonist (VKA) therapy is challenging in children because of a narrow therapeutic range and wide inter- and intra-individual variability in dose response. Only a few small studies have investigated the effect of nongenetic and genetic factors on the dose response to VKAs in children. In a cohort study including 118 children (median age 9 years; range, 3 months-18 years) mostly with cardiac disease, we evaluated by multivariate analysis the relative contribution of nongenetic factors and VKORC1/CYP2C9/CYP4F2 genotypes on warfarin (n = 83) or fluindione (n = 35) maintenance dose and the influence of these factors on the time spent within/above/below the range. The results showed that height, target international normalized ratio and VKORC1 and CYP2C9 genotypes were the main determinants of warfarin dose requirement, accounting for 48.1%, 4.4%, 18.2%, and 2.0% of variability, respectively, and explaining 69.7% of the variability. Our model predicted the warfarin dose within 7 mg/wk in 86.7% of patients. None of the covariates was associated with the time spent above or below the international normalized ratio range. Whether this model predicts accurately the effective maintenance dose is currently being investigated.
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Affiliation(s)
- Liewei Wang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Medical School, Mayo Clinic, Rochester, MN 55905, USA
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