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Clinical and genetic factors influencing acenocoumarol dosing: a cross-sectional study. Blood Coagul Fibrinolysis 2018; 29:496-500. [PMID: 29916837 DOI: 10.1097/mbc.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Coumadin oral anticoagulants are widely used in multiple clinical scenarios. Their narrow therapeutic range and a dosing strategy based on 'a posteriori' algorithms, pose them as an interesting group for prediction modelling research. Extensive literature explaining the association between clinical and genetic variables with the dose of warfarin have been published. Limited information exists regarding these factors and acenocoumarol dosing. The aim of the study is to explain through clinical/genetic variables, the weekly dose of acenocoumarol necessary for achieving stable anticoagulation status. We performed a cross-sectional study enrolling adults under treatment with acenocoumarol with at least three consecutive INRs between 2 and 3. To explain the association between demographic, clinical and genotype data (VKORC1, CYP2C9 and CYP4F2) and the mean weekly dose of acenocoumarol, we performed a multiple linear regression model. In our cohort, a higher age, the presence of atrial fibrillation, chronic renal failure and VKORC1 haplotype A were associated with a lower mean weekly dose of acenocoumarol. On the other side, a higher weight was associated with a higher weekly dose. Amongst anticoagulated adult patients, VKORC1 genotype and baseline clinical factors can explain acenocoumarol dosing, and therefore, help clinicians while deciding the initial anticoagulant dose.
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Serna MJ, Rivera-Caravaca JM, Gonzalez-Conejero R, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Roldán V, Marín F. Pharmacogenetics of vitamin K antagonists and bleeding risk prediction in atrial fibrillation. Eur J Clin Invest 2018; 48:e12929. [PMID: 29577257 DOI: 10.1111/eci.12929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Polymorphisms in the vitamin K epoxide reductase complex 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) genes increase the bleeding risk in anticoagulated atrial fibrillation (AF) patients. Here, we aimed to investigate whether VKORC1 and CYP2C9 polymorphisms improved the predictive performance for major bleeding using the HAS-BLED score. MATERIAL AND METHODS We recruited 652 consecutive AF patients stable on vitamin K antagonist (INR 2.0-3.0) during at least the previous 6 months. A baseline venous blood sample was obtained for DNA extraction. We gave an extra point to the HAS-BLED score if the patient was a simultaneous carrier of the VKORC1 and CYP2C9 polymorphisms related to bleeding, and we called this modified score "GEN|HAS-BLED." During a median follow-up of 7.6 years (IQR 5.6-8.0), all major bleeding events were recorded. RESULTS During follow-up, 106 (16.2%) patients experienced a major bleeding (2.81%/y; 42 intracranial haemorrhages and 44 gastrointestinal bleeding) and 24 (3.7%) died from major bleeding (0.48%/y). Cox regression analyses demonstrated a significant association between HAS-BLED or GEN|HAS-BLED and major bleeds, both as continuous or categorical scores. Comparison of receiver operating characteristic (ROC) curves shows that original HAS-BLED clinical score had better predictive ability than GEN|HAS-BLED (0.660, 95% CI 0.622-0.696 vs 0.645, 95% CI 0.607-0.682; P = .030). Discrimination and reclassification analyses showed that GEN|HAS-BLED did not improve sensitivity compared with the original score and even showed significant negative reclassification. CONCLUSION Adding pharmacogenetic factors (ie polymorphisms of the VKORC1 and CYP2C9 genes) to the HAS-BLED score does not improve the prediction or discrimination performance for major bleeding.
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Affiliation(s)
- María José Serna
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Rocío Gonzalez-Conejero
- Centro Regional de Hemodonación, Universidad de Murcia, CIBERER, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Centro Regional de Hemodonación, Universidad de Murcia, CIBERER, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
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Ragia G, Karantza IM, Kelli-Kota E, Kolovou V, Kolovou G, Konstantinides S, Maltezos E, Tavridou A, Tziakas D, Maitland-van der Zee AH, Manolopoulos VG. Role of CYP4F2, CYP2C19, and CYP1A2 polymorphisms on acenocoumarol pharmacogenomic algorithm accuracy improvement in the Greek population: need for sub-phenotype analysis. Drug Metab Pers Ther 2017; 32:183-190. [PMID: 29252193 DOI: 10.1515/dmpt-2017-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND We have earlier developed a pharmacogenomic algorithm for acenocoumarol dose prediction in Greek patients that included CYP2C9/VKORC1 genetic information. This study aims at analyzing the potential effect of CYP4F2, CYP2C19, and CYP1A2 gene polymorphisms on acenocoumarol dose requirements and at further improving the Greek-specific pharmacogenomic algorithm. METHODS A total of 205 Greek patients taking acenocoumarol (140 who reached and 65 who did not reach stable dose), participants of acenocoumarol EU-PACT trial, were included in the study. CYP4F2, CYP2C19, and CYP1A2 polymorphisms were genotyped by use of the PCR-RFLP method. All patients were previously genotyped for CYP2C9/VKORC1 polymorphisms. RESULTS In the pooled sample, CYP4F2, CYP2C19, and CYP1A2 polymorphisms do not affect independently acenocoumarol dose requirements. For CYP4F2, significant effects were found on patients' ability to reach stable dose and on acenocoumarol dose requirements when CYP2C9/VKORC1 sub-phenotypes were analyzed. Specifically, when the patients were stratified according to their CYP2C9/VKORC1 functional bins, in sensitive responders, CYP4F2*3 allele carriers (CYP4F2 *1/*3 and *3/*3 genotypes) were more frequent in the patient group who reached stable dose (p=0.049). Additionally, in CYP2C9 intermediate metabolizers (IMs), after adjusting for age, weight, and VKORC1 genotypes, CYP4F2 genotypes were significantly associated with acenocoumarol stable dose (β: 0.07; 95% CI: 0.006-0.134; p=0.033). CONCLUSIONS CYP4F2 gene shows a prominent weak association with acenocoumarol dose requirements. Sub-phenotype analysis is potentially important in determining additional gene polymorphisms that are associated with acenocoumarol dose requirements.
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Affiliation(s)
- Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Dragana Campus, 68100 Alexandroupolis, Greece, Phone: +30 2551 030523, Fax: +30 2551 030523; and DNALEX S.A., Alexandroupolis, Greece
| | - Ioanna-Maria Karantza
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Eleni Kelli-Kota
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vana Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Genovefa Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Konstantinides
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anna Tavridou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Tziakas
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anke H Maitland-van der Zee
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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Cerezo-Manchado JJ, Roldán V, Corral J, Rosafalco M, Antón AI, Padilla J, González-Conejero R, Vicente V. Genotype-guided therapy improves initial acenocoumarol dosing. Thromb Haemost 2017; 115:117-25. [DOI: 10.1160/th14-09-0814] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 08/06/2015] [Indexed: 11/05/2022]
Abstract
SummaryA few trials so far have evaluated the effectiveness of algorithms designed to calculate doses in oral anticoagulant therapy, with negative or contradictory results. We compared a genotype-guided algorithm vs physician management for the initiation of acenocoumarol. In a twoarm, prospective, randomised study with patients with atrial fibrillation who started therapy, the first dose was administered to all patients according to the physician’s criteria. At 72 hours, the corresponding dose was calculated based on INR in the standard care group (SC, N=92), whereas genetic data (VKORC1, CYP2C9 and CYP4F2) were also considered for the genotype-guided dosing (pharmacogenetic) group (PGx, N=87) by using an algorithm previously validated in 2,683 patients. The primary outcomes were: patients with steady dose, the time needed to reach the same and the percentage of therapeutic INRs. After 90 days, 25 % of the SC and 39 % of the PGx patients reached the steady dose (p=0.038). Kaplan-Meier analysis showed that PGx group needed fewer days to reach therapeutic INR (p=0.033). Additionally, PGx had a higher percentage of therapeutic INRs than SC patients (50 % and 45 %, respectively) (p=0.046). After six months the proportion of steadily anticoagulated patients remained significantly higher in PGx (p=0.010). In conclusion, genotype-guided dosing was associated with a higher percentage of patients with steady dose than routine practice when starting oral anticoagulation with acenocoumarol.
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Sychev DA, Rozhkov AV, Ananichuk AV, Kazakov RE. Evaluation of genotype-guided acenocoumarol dosing algorithms in Russian patients. Drug Metab Pers Ther 2017; 32:109-114. [PMID: 28525318 DOI: 10.1515/dmpt-2016-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/28/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acenocoumarol dose is normally determined via step-by-step adjustment process based on International Normalized Ratio (INR) measurements. During this time, the risk of adverse reactions is especially high. Several genotype-based acenocoumarol dosing algorithms have been created to predict ideal doses at the start of anticoagulant therapy. METHODS Nine dosing algorithms were selected through a literature search. These were evaluated using a cohort of 63 patients with atrial fibrillation receiving acenocoumarol therapy. RESULTS None of the existing algorithms could predict the ideal acenocoumarol dose in 50% of Russian patients. The Wolkanin-Bartnik algorithtm based on European population was the best-performing one with the highest correlation values (r=0.397), mean absolute error (MAE) 0.82 (±0.61). EU-PACT also managed to give an estimate within the ideal range in 43% of the cases. The two least accurate results were yielded by the Indian population-based algorithms. Among patients receiving amiodarone, algorithms by Schie and Tong proved to be the most effective with the MAE of 0.48±0.42 mg/day and 0.56±0.31 mg/day, respectively. CONCLUSIONS Patient ethnicity and amiodarone intake are factors that must be considered when building future algorithms. Further research is required to find the perfect dosing formula of acenocoumarol maintenance doses in Russian patients.
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Chen P, Sun YQ, Yang GP, Li R, Pan J, Zhou YS. Influence of the CYP4F2 polymorphism on the risk of hemorrhagic complications in coumarin-treated patients. Saudi Med J 2016; 37:361-8. [PMID: 27052278 PMCID: PMC4852013 DOI: 10.15537/smj.2016.4.14036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objectives: To evaluate the impact of the CYP4F2 polymorphism on bleeding complications and over-anticoagulation due to coumarin. Methods: A comprehensive literature search was performed to look for eligible studies published prior to February 2015 in EMBASE and PubMed. References were strictly identified by inclusion and exclusion criteria, and authors of primary studies were consulted for additional information and data. Revman 5.3 software was used to analyze the impact of the CYP4F2 polymorphism on hemorrhagic complications and over-anticoagulation events (international normalized ratio >4). Results: Eight studies involving 3,101 samples met the specified inclusion criteria. Compared with wild-type homozygotes (CYP4F2*1*1), carriers of the CYP4F2*3 variant had no significant effects on total bleeding events (odds ratio [OR]: 0.86; 95% confidence interval [CI]: 0.71-1.05; p=0.15), major hemorrhage complications in coumarin users (OR: 0.80; 95% CI: 0.64-1.01; p=0.06). Patients carried CYP4F2*3 also had nonsignificant associations with the risk of over-anticoagulation (relative risk [RR]: 079; 95% CI: 0.59-1.06; p=0.12). We found a lower risk in patients with homozygotes for CYP4F2*3, but there was no statistical significance (RR: 0.66; 95% CI: 0.43-1.01; p=0.05). Conclusion: This meta-analysis indicated the impact of the CYP4F2 polymorphism on bleeding complications and over-anticoagulation in coumarin-treated patients failed to reach the level of statistical significance. However, large-scale and well designed studies are necessary to determine conclusively the association between the CYP4F2 polymorphism and hemorrhage risk.
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Affiliation(s)
- Peng Chen
- Institute of Pharmacy & Pharmacology, University of South China, Hengyang, Hunan, China. E-mail.
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