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Xue L, Singla RK, He S, Arrasate S, González-Díaz H, Miao L, Shen B. Warfarin-A natural anticoagulant: A review of research trends for precision medication. Phytomedicine 2024; 128:155479. [PMID: 38493714 DOI: 10.1016/j.phymed.2024.155479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/29/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Warfarin is a widely prescribed anticoagulant in the clinic. It has a more considerable individual variability, and many factors affect its variability. Mathematical models can quantify the quantitative impact of these factors on individual variability. PURPOSE The aim is to comprehensively analyze the advanced warfarin dosing algorithm based on pharmacometrics and machine learning models of personalized warfarin dosage. METHODS A bibliometric analysis of the literature retrieved from PubMed and Scopus was performed using VOSviewer. The relevant literature that reported the precise dosage of warfarin calculation was retrieved from the database. The multiple linear regression (MLR) algorithm was excluded because a recent systematic review that mainly reviewed this algorithm has been reported. The following terms of quantitative systems pharmacology, mechanistic model, physiologically based pharmacokinetic model, artificial intelligence, machine learning, pharmacokinetic, pharmacodynamic, pharmacokinetics, pharmacodynamics, and warfarin were added as MeSH Terms or appearing in Title/Abstract into query box of PubMed, then humans and English as filter were added to retrieve the literature. RESULTS Bibliometric analysis revealed important co-occuring MeShH and index keywords. Further, the United States, China, and the United Kingdom were among the top countries contributing in this domain. Some studies have established personalized warfarin dosage models using pharmacometrics and machine learning-based algorithms. There were 54 related studies, including 14 pharmacometric models, 31 artificial intelligence models, and 9 model evaluations. Each model has its advantages and disadvantages. The pharmacometric model contains biological or pharmacological mechanisms in structure. The process of pharmacometric model development is very time- and labor-intensive. Machine learning is a purely data-driven approach; its parameters are more mathematical and have less biological interpretation. However, it is faster, more efficient, and less time-consuming. Most published models of machine learning algorithms were established based on cross-sectional data sourced from the database. CONCLUSION Future research on personalized warfarin medication should focus on combining the advantages of machine learning and pharmacometrics algorithms to establish a more robust warfarin dosage algorithm. Randomized controlled trials should be performed to evaluate the established algorithm of warfarin dosage. Moreover, a more user-friendly and accessible warfarin precision medicine platform should be developed.
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Affiliation(s)
- Ling Xue
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China; Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China; Department of Pharmacology, Faculty of Medicine, University of The Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
| | - Rajeev K Singla
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China; School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab-144411, India
| | - Shan He
- IKERDATA S.l., ZITEK, University of The Basque Country (UPVEHU), Rectorate Building, 48940, Bilbao, Basque Country, Spain; Department of Organic and Inorganic Chemistry, Faculty of Science and Technology, University of The Basque Country (UPV/EHU), P.O. Box 644, 48080, Bilbao, Basque Country, Spain
| | - Sonia Arrasate
- Department of Organic and Inorganic Chemistry, Faculty of Science and Technology, University of The Basque Country (UPV/EHU), P.O. Box 644, 48080, Bilbao, Basque Country, Spain
| | - Humberto González-Díaz
- Department of Organic and Inorganic Chemistry, Faculty of Science and Technology, University of The Basque Country (UPV/EHU), P.O. Box 644, 48080, Bilbao, Basque Country, Spain; BIOFISIKA: Basque Center for Biophysics CSIC, University of The Basque Country (UPV/EHU), Barrio Sarriena s/n, Leioa, Bizkaia 48940, Basque Country, Spain; IKERBASQUE, Basque Foundation for Science, 48011, Bilbao, Basque Country, Spain
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China; College of Pharmaceutical Sciences, Soochow University, Suzhou, China.
| | - Bairong Shen
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China.
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Yazbeck A, Akika R, Awada Z, Zgheib NK. Pharmacogenetic considerations in therapy with novel antiplatelet and anticoagulant agents. Pharmacogenet Genomics 2024; 34:61-72. [PMID: 38372412 DOI: 10.1097/fpc.0000000000000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Antiplatelets and anticoagulants are extensively used in cardiovascular medicine for the prevention and treatment of thrombosis in the venous and arterial circulations. Wide inter-individual variability has been observed in response to antiplatelets and anticoagulants, which triggered researchers to investigate the genetic basis of this variability. Data from extensive pharmacogenetic studies pointed to strong evidence of association between polymorphisms in candidate genes and the pharmacokinetics and pharmacodynamic action and clinical response of the antiplatelets clopidogrel and the anticoagulant warfarin. In this review, we conducted an extensive search on Medline for the time period of 2009-2023. We also searched the PharmGKB website for levels of evidence of variant-drug combinations and for drug labels and clinical guidelines. We focus on the pharmacogenetics of novel antiplatelets and anticoagulants while excluding acetylsalicylic acid, warfarin and heparins, and discuss the current knowledge with emphasis on the level of evidence.
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Affiliation(s)
| | - Reem Akika
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Zainab Awada
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nathalie K Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Hirai T, Aoyama T, Tsuji Y, Itoh T, Matsumoto Y, Iwamoto T. Kinetic-pharmacodynamic model of warfarin for prothrombin time-international normalized ratio in Japanese patients. Br J Clin Pharmacol 2024; 90:828-836. [PMID: 37953511 DOI: 10.1111/bcp.15967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/10/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Genotype-guided dosing algorithms can explain about half of the interindividual variability in prothrombin time-international normalized ratio (PT-INR) under warfarin treatment. This study aimed to refine a published kinetic-pharmacodynamic model and guide warfarin dosage for an optimal PT-INR based on renal function. METHODS Using a retrospective cohort of adult patients (>20 years) who were administered warfarin and underwent PT-INR measurements, we refined the kinetic-pharmacodynamic model with age and the genotypes of cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 using the PRIOR subroutine in the nonlinear-mixed-effect modelling programme. We searched the significant covariates for parameters, such as the dose rate for 50% inhibition of coagulation (EDR50 ), using a stepwise forward and backward method. Monte Carlo simulation determined a required daily dose of warfarin with a target range of PT-INR (2.0-3.0 or 1.6-2.6) based on the significant covariates. RESULTS A total of 350 patients with 2762 PT-INR measurements were enrolled (estimated glomerular filtration rate [eGFR]: 47.5 [range: 2.6-199.0] mL/min/1.73 m2 ). The final kinetic-pharmacodynamic model showed that the EDR50 changed power functionally with body surface area, serum albumin level and eGFR. Monte Carlo simulation revealed that a lower daily dose of warfarin was required to attain the target PT-INR range as eGFR decreased. CONCLUSIONS Model-informed precision dosing of warfarin is a valuable approach for estimating its dosage in patients with renal impairment.
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Affiliation(s)
- Toshinori Hirai
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, Tsu, Mie, Japan
| | - Takahiko Aoyama
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Yasuhiro Tsuji
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Toshimasa Itoh
- Department of Pharmacy, Tokyo Women's Medical University, Medical Center East, Tokyo, Japan
| | - Yoshiaki Matsumoto
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, Tsu, Mie, Japan
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Zenklusen I, Dingemanse J, Reh C, Gehin M, Kaufmann P. Effect of Daridorexant on the Pharmacokinetics of Midazolam, and on the Pharmacokinetics and Pharmacodynamics of Warfarin in Healthy Male Subjects. Drugs R D 2024; 24:97-108. [PMID: 38472696 PMCID: PMC11035509 DOI: 10.1007/s40268-024-00456-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Daridorexant, a dual orexin receptor antagonist was recently approved for the treatment of insomnia at doses up to 50 mg once per night. This study investigated the effect of single-dose and multiple-dose daridorexant 50 mg at steady state on the pharmacokinetics (PK) of the cytochrome P450 (CYP) 3A4-sensitive substrate midazolam, and the effect of single-dose daridorexant 50 mg on the PK and pharmacodynamics (PD) of the CYP2C9-sensitive substrate warfarin. METHODS In this prospective, single-center, open-label, fixed-sequence, phase I, drug-drug interaction study, 18 healthy male subjects sequentially received Treatment A, B, and C in three periods. Treatment A consisted of a single oral concomitant administration of midazolam 2 mg and warfarin 25 mg on day 1 of the first period. Treatment B consisted of one oral administration of daridorexant 50 mg followed 1 h later by a single oral dose of midazolam 2 mg concomitantly with a single oral dose of warfarin 25 mg on day 1 and a once-daily oral administration of daridorexant 50 mg for 6 days of the second period. Treatment C consisted of a single oral administration of daridorexant 50 mg at steady state followed 1 h later by a single oral administration of midazolam 2 mg on day 1 of the third period. Blood samples were assessed for midazolam and S-warfarin PK, and PD (international normalized ratio and factor VII). Noncompartmental PK parameters and PD variables were evaluated with geometric mean ratios and 90% confidence intervals of Treatment B/A versus C/A for midazolam, and treatment B/A for warfarin. Safety and tolerability of each treatment were also assessed. RESULTS Midazolam maximum plasma concentration (Cmax) and area under the plasma concentration-time curve from 0 to 24 h (AUC0-24) were 1.13- and 1.42-fold higher, respectively, after single-dose administration of daridorexant 50 mg compared to administration of midazolam alone, while Cmax and AUC0-24 were 1.12- and 1.35-fold higher, respectively, after administration of daridorexant 50 mg once daily at steady state. Terminal half-life and time to maximum plasma concentration were comparable between treatments. Daridorexant had no influence on the PK and PD of warfarin. All treatments were safe and well tolerated. CONCLUSIONS Daridorexant at 50 mg is classified as a weak CYP3A4 inhibitor after single- and multiple-dose administration once daily at steady state. Daridorexant 50 mg did not induce CYP3A4 activity or inhibit CYP2C9 activity. CLINICAL TRIAL REGISTRATION This trial (NCT05480488) was registered on 29 July, 2022.
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Affiliation(s)
- Isabelle Zenklusen
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | - Martine Gehin
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland.
| | - Priska Kaufmann
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
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Zhao Y, Yang C, Liu Y, Qin M, Sun J, Liu G. Effects of sodium ferulate for injection on anticoagulation of warfarin in rats in vivo. BMC Complement Med Ther 2024; 24:87. [PMID: 38355450 PMCID: PMC10865636 DOI: 10.1186/s12906-024-04389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/03/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Herb-drug interactions may result in increased adverse drug reactions or diminished drug efficacy, especially for drugs with a narrow therapeutic index such as warfarin. The current study investigates the effects of sodium ferulate for injection (SFI) on anticoagulation of warfarin from aspects of pharmacodynamics and pharmacokinetics in rats and predicts the risk of the combination use. METHODS Rats were randomly divided into different groups and administered single- or multiple-dose of warfarin (0.2 mg/kg) with or without SFI of low dose (8.93 mg/kg) or high dose (26.79 mg/kg). Prothrombin time (PT) and activated partial thromboplastin time (APTT) were detected by a blood coagulation analyzer, and international normalized ratio (INR) values were calculated. UPLC-MS/MS was conducted to measure concentrations of warfarin enantiomers and pharmacokinetic parameters were calculated by DAS2.0 software. RESULTS The single-dose study demonstrated that SFI alone had no effect on coagulation indices, but significantly decreased PT and INR values of warfarin when the two drugs were co-administered (P < 0.05 or P < 0.01), while APTT values unaffected (P > 0.05). Cmax and AUC of R/S-warfarin decreased but CL increased significantly in presence of SFI (P < 0.01). The multiple-dose study showed that PT, APTT, INR, and concentrations of R/S-warfarin decreased significantly when SFI was co-administered with warfarin (P < 0.01). Warfarin plasma protein binding rate was not significantly changed by SFI (P > 0.05). CONCLUSIONS The present study implied that SFI could accelerate warfarin metabolism and weaken its anticoagulation intensity in rats.
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Affiliation(s)
- Yue Zhao
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, 150086, P.R. China
| | - Chunjuan Yang
- College of Pharmacy, Harbin Medical University, Harbin, 150086, P.R. China
| | - Yan Liu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, 150086, P.R. China
| | - Mengnan Qin
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, 150086, P.R. China
| | - Jiahui Sun
- College of Pharmacy, Harbin Medical University, Harbin, 150086, P.R. China
| | - Gaofeng Liu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, 150086, P.R. China.
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Liu Y, Sun J, Yang C, Qin M, Xu S, Zhao Y, Liu G. Safflower yellow for injection enhances anti-coagulation of warfarin in rats: implications in pharmacodynamics and pharmacokinetics. Xenobiotica 2024; 54:75-82. [PMID: 38445636 DOI: 10.1080/00498254.2024.2326987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/02/2024] [Indexed: 03/07/2024]
Abstract
This study investigated whether Safflower Yellow for injection (SYI) would affect the anticoagulation of warfarin in rats.Wistar male rats were divided into six groups randomly and administered with SYI (9 mg/kg, intraperitoneal injection) in single-dose and steady-dose warfarin (0.2 mg/kg, oral gavage), respectively. The pharmacodynamic parameters of PT and APTT were measured by a coagulation analyser. R/S-warfarin concentration was measured by UHPLC-MS/MS, and pharmacokinetic parameters calculated using DAS 2.0 software.The single-dose study demonstrated that SYI, alone or co-administered with warfarin, could significantly increase PT, INR, and APTT values (p < 0.01). R-warfarin Cmax, AUC, and t1/2 values increased by 9.25% (p > 0.05), 25.96% (p < 0.01), and 26.17% (p < 0.01), respectively, whereas the CL/F value reduced by 22.22% (p < 0.01) in the presence of SYI. Meanwhile, S-warfarin Cmax, AUC, and t1/2 values increased by 37.41%, 32.11%, and 31.73% (all p < 0.01), respectively, whereas the CL/F value reduced by 33.33% (p < 0.01). The steady-dose study showed that PT, INR, APTT, and the concentrations of R/S-warfarin increased significantly when SYI was co-administered with warfarin (p < 0.01).SYI can enhance warfarin's anticoagulation intensity and decelerate its metabolism in rats.
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Affiliation(s)
- Yan Liu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, China
| | - Jiahui Sun
- College of Pharmacy, Harbin Medical University, Harbin, China
| | - Chunjuan Yang
- College of Pharmacy, Harbin Medical University, Harbin, China
| | - Mengnan Qin
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, China
| | - Shiwei Xu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, China
| | - Yue Zhao
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, China
| | - Gaofeng Liu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, China
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He X, Liu G, Chen X, Wang Y, Liu R, Wang C, Huang Y, Shen J, Jia Y. Pharmacokinetic and Pharmacodynamic Interactions Between Henagliflozin, a Novel Selective SGLT-2 Inhibitor, and Warfarin in Healthy Chinese Subjects. Clin Ther 2023; 45:655-661. [PMID: 37451912 DOI: 10.1016/j.clinthera.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/28/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE While controlling blood glucose, patients with diabetes and abnormal coagulation should be treated with positive anticoagulation because the hypercoagulable state of their blood is the primary cause of macroangiopathy. The goal of this study was to evaluate the pharmacokinetic and pharmacodynamic (PK/PD) interactions between henagliflozin, a novel selective sodium-glucose cotransporter 2 inhibitor, and warfarin in healthy subjects. METHODS This single-center, open-label, single-arm clinical study was conducted in 16 healthy male Chinese subjects. According to the study protocol, the PK properties of henagliflozin 10 mg/d and warfarin 5 mg/d were collected and tabulated in accordance with sampling time. All study drugs were given with once-daily administration. Subjects were monitored for adverse reactions and their severity, outcomes, and relationship to study drug. This influences of warfarin on the PK properties of henagliflozin (Cmax,ss and AUCτ,ss), the effects of henagliflozin on the PK properties of warfarin (Cmax, AUC0-t, and AUC0-∞), and the influences of henagliflozin on the PD properties of warfarin (PTmax, PTAUC, INRmax, and INRAUC) were evaluated. FINDINGS The geometric mean ratios (GMRs; 90% CIs) of henagliflozin Cmax,ss and AUCτ,ss were 101.75% (96.11%-107.72%) and 102.21% (100.04%-104.42%), respectively. The GMRs (90% CIs) of S- and R-warfarin Cmax, AUC0-t, and AUC0-∞ were as follows: Cmax, 114.31% (106.30%-122.91%) and 115.09% (109.46%-121.01%), respectively; AUC0-t, 120.15% (116.71%-123.69%) and 119.01% (116.32%-121.76%); and AUC0-∞, 120.81% (117.17%-124.58%) and 121.94% (118.90%-125.05%). The GMRs (90% CIs) of warfarin PTmax and PTAUC were 92.73% (91.25%-94.22%) and 97.42% (96.61%-98.24%). The GMRs (90% CIs) of warfarin INRmax and INRAUC were 92.66% (91.17%-94.17%) and 97.36% (96.52%-98.21%). A total of 32 cases of mild adverse events were reported, and were recovered/resolved. There were no serious adverse events reported. IMPLICATIONS No significant clinically relevant effects on the PK/PD properties of henagliflozin or warfarin were found with coadministration of the two drugs in these healthy male Chinese subjects. Based on these findings, it is expected that henagliflozin and warfarin can be used in combination without dose adjustment. Chinadrugtrials.org.cn identifier: CTR20190240.
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Affiliation(s)
- Xuejun He
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China
| | - Gege Liu
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China
| | - Xinyan Chen
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China
| | - Yaqin Wang
- Anhui Provincial Center of Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, People's Republic of China
| | - Ran Liu
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China
| | - Changmao Wang
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China
| | - Yunzhe Huang
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China
| | - Jie Shen
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China; Anhui Provincial Center of Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, People's Republic of China
| | - Yuanwei Jia
- School of Pharmacy, Wannan Medical College, Wuhu, People's Republic of China; Anhui Provincial Center of Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, People's Republic of China.
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Cheng S, Flora DR, Rettie AE, Brundage RC, Tracy TS. A Physiological-Based Pharmacokinetic Model Embedded with a Target-Mediated Drug Disposition Mechanism Can Characterize Single-Dose Warfarin Pharmacokinetic Profiles in Subjects with Various CYP2C9 Genotypes under Different Cotreatments. Drug Metab Dispos 2023; 51:257-267. [PMID: 36379708 PMCID: PMC9901215 DOI: 10.1124/dmd.122.001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/10/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
Warfarin, a commonly prescribed oral anticoagulant medication, is highly effective in treating deep vein thrombosis and pulmonary embolism. However, the clinical dosing of warfarin is complicated by high interindividual variability in drug exposure and response and its narrow therapeutic index. CYP2C9 genetic polymorphism and drug-drug interactions (DDIs) are substantial contributors to this high variability of warfarin pharmacokinetics (PK), among numerous factors. Building a physiology-based pharmacokinetic (PBPK) model for warfarin is not only critical for a mechanistic characterization of warfarin PK but also useful for investigating the complicated dose-exposure relationship of warfarin. Thus, the objective of this study was to develop a PBPK model for warfarin that integrates information regarding CYP2C9 genetic polymorphisms and their impact on DDIs. Generic PBPK models for both S- and R-warfarin, the two enantiomers of warfarin, were constructed in R with the mrgsolve package. As expected, a generic PBPK model structure did not adequately characterize the warfarin PK profile collected up to 15 days following the administration of a single oral dose of warfarin, especially for S-warfarin. However, following the integration of an empirical target-mediated drug disposition (TMDD) component, the PBPK-TMDD model well characterized the PK profiles collected for both S- and R-warfarin in subjects with different CYP2C9 genotypes. Following the integration of enzyme inhibition and induction effects, the PBPK-TMDD model also characterized the PK profiles of both S- and R-warfarin in various DDI settings. The developed mathematic framework may be useful in building algorithms to better inform the clinical dosing of warfarin. SIGNIFICANCE STATEMENT: The present study found that a traditional physiology-based pharmacokinetic (PBPK) model cannot sufficiently characterize the pharmacokinetic profiles of warfarin enantiomers when warfarin is administered as a single dose, but a PBPK model with a target-mediated drug disposition mechanism can. After incorporating CYP2C9 genotypes and drug-drug interaction information, the developed model is anticipated to facilitate the understanding of warfarin disposition in subjects with different CYP2C9 genotypes in the absence and presence of both cytochrome P450 inhibitors and cytochrome P450 inducers.
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Affiliation(s)
- Shen Cheng
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, Minnesota (S.C., D.R.F., R.C.B.); Tracy Consultants, Huntsville, Alabama (T.S.T.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (A.E.R.)
| | - Darcy R Flora
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, Minnesota (S.C., D.R.F., R.C.B.); Tracy Consultants, Huntsville, Alabama (T.S.T.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (A.E.R.)
| | - Allan E Rettie
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, Minnesota (S.C., D.R.F., R.C.B.); Tracy Consultants, Huntsville, Alabama (T.S.T.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (A.E.R.)
| | - Richard C Brundage
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, Minnesota (S.C., D.R.F., R.C.B.); Tracy Consultants, Huntsville, Alabama (T.S.T.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (A.E.R.)
| | - Timothy S Tracy
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, Minnesota (S.C., D.R.F., R.C.B.); Tracy Consultants, Huntsville, Alabama (T.S.T.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (A.E.R.)
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Velizarova M, Abedinov P, Svinarov D, Nikolov V, Hristova J. Frequency Distribution of CYP2C9 and VKORC1 Mutations among Bulgarian Patients and their Importance for Anticoagulant Therapy. Clin Lab 2022; 68. [PMID: 36546741 DOI: 10.7754/clin.lab.2022.220213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Genetic polymorphisms of CYP2C9 and VKORC1 play a major role in pharmacokinetics and pharmacodynamics of coumarin anticoagulants. The purpose of our study was to assess the relative frequency of the above mutations in Bulgarian population in order to predict bleeding tendencies and precisely manage the anticoagulant therapy during the postoperative period after cardiac surgery with extracorporeal circulation. METHODS Genomic DNA samples from 200 Bulgarian patients subjected to cardiac surgery with extracorporeal circulation were analyzed for VKORC1 1639G>A and CYP2C9*2&*3 polymorphisms by real-time polymerase chain reaction (PCR), then allele frequencies of various genotypes were calculated by Hardy-Weinberg Equilibrium. RESULTS Median patients' age was 63.9 ± 10.8 years; 66.5% were male. Median BMI was 28.6 ± 5.4 kg/m2. Genotype distribution for CYP2C9 was *1/*1 - 51%, *1/*2 - 21%, *1/*3 - 13.5%, *2/*3 - 4%, *3/*3 - 2%, and *2/*2 - 1.5%. The calculated frequency of CYP2C9*1 allele was 74.25%, CYP2C9*2 allele was 13%, and CYP2C9*3 allele was 12.75%, and all allelic frequencies were in Hardy-Weinberg equilibrium (p-value = 0.358). The major VKORC1 genotype was G/A - 47%, followed by G/G - 35.5% and A/A - 17.5%). Based on Hardy-Weinberg Equilibrium, there was no significant difference between observed and expected frequencies (X - -3.779), presumably as a result of the homogeneity in the population. CONCLUSIONS Analysis of the data obtained in the course of the study suggested that identification of homozygous carriers of VKORC1-1639 G>A (rs9923231) in Bulgarians may be useful in developing recommendations for personalized therapy. On the contrary, homozygous carriers of CYP2C9*2 or *3, included only 4.5% of the studied patients, thus indicating that this group would benefit less from dosing algorithms. Our results demonstrated good agreement with the results obtained in other studies conducted in the Caucasian population.
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Rusdiana T, Mardhiani YD, Putriana NA, Gozali D, Nagano D, Araki T, Yamamoto K. The influence of Javanese turmeric ( Curcuma xanthorrhiza) on the pharmacokinetics of warfarin in rats with single and multiple-dose studies. Pharm Biol 2021; 59:639-646. [PMID: 34062109 PMCID: PMC8172219 DOI: 10.1080/13880209.2021.1928716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
CONTEXT Co-administration between warfarin (WF) and Curcuma xanthorrhiza Roxb. (Zingiberaceae) (CX) is found in Indonesian patients and need to be evaluated. OBJECTIVE This study assesses the effect of concomitant administration of CX extract on the pharmacokinetics of WF in rats. MATERIALS AND METHODS Wistar rats were divided into 4 groups (n = 6) and administered with 2% Pulvis Gummi Arabicum (PGA, control), fluconazole (FZ, 6 mg/kg), CX-1 (6 mg/kg) or CX-2 (18 mg/kg BW) for 7 days. For the single-dose study, at the 8th day, WF (1 mg/kg) was administered to all groups and blood samples were taken from 0.25 to 72 h. For the multiple-dose study, daily dose of WF was administered to all groups of rats and at the 7th to 9th day, the rats were treated with PGA, CX-1, CX-2 and FZ. Blood samples were withdrawn daily at 4 h after administration of WF from the 1st to 11th day. RESULTS The area under the curve (AUC) of R- and S-WF in the CX-2 group was a significantly higher value compared to the control (77.54 vs. 35.27 mg.h/L for R-WF and 316.26 vs. 40.16 mg.h/L for S-WF; p < 0.05; Kruskal-Wallis method). The CX-2 administration also caused the increasing in the concentration level of R-WF (16%) and S-WF (27%) from the 7th to 9th day of administration. DISCUSSION AND CONCLUSIONS The CX administration in a higher dose caused alteration on WF pharmacokinetics suggesting the need for clinical evaluation of the interaction between CX and WF.
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Affiliation(s)
- Taofik Rusdiana
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, Indonesia
- CONTACT Taofik Rusdiana Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Universitas Padjadjaran, Jl. Raya Bandung-Sumedang km 21, Jatinangor, Sumedang, West Java45363, Indonesia
| | | | - Norisca A. Putriana
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, Indonesia
| | - Dolih Gozali
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, Indonesia
| | - Daisuke Nagano
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takuya Araki
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Koujirou Yamamoto
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Medicine, Gunma University, Maebashi, Japan
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11
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Halkin H. Pharmacokinetic Drug Interactions of the New Oral Anticoagulants Revisited. Clin Pharmacol Ther 2021; 112:208-209. [PMID: 34787312 DOI: 10.1002/cpt.2447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/08/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Hillel Halkin
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University School of Medicine, Tel Aviv, Israel
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12
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Tanaka T, Ihara M, Fukuma K, Yamamoto H, Washida K, Kimura S, Kada A, Miyata S, Miyata T, Nagatsuka K. Influence of Renal Impairment and Genetic Subtypes on Warfarin Control in Japanese Patients. Genes (Basel) 2021; 12:genes12101537. [PMID: 34680932 PMCID: PMC8535514 DOI: 10.3390/genes12101537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022] Open
Abstract
The genotypes of vitamin K epoxide reductase complex 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) can influence therapeutic warfarin doses. Conversely, nongenetic factors, especially renal function, are associated with warfarin maintenance doses; however, the optimal algorithm for considering genes and renal dysfunction has not been established. This single-center prospective cohort study aimed to evaluate the factors affecting warfarin maintenance doses and develop pharmacogenetics-guided algorithms, including the factors of renal impairment and others. To commence, 176 outpatients who were prescribed warfarin for thromboembolic stroke prophylaxis in the stroke center, were enrolled. Patient characteristics, blood test results, dietary vitamin K intake, and CYP2C9 and VKORC1 (-1639G>A) genotypes were recorded. CYP2C9 and VKORC1 (-1639G>A) genotyping revealed that 80% of the patients had CYP2C9 *1/*1 and VKORC1 mutant AA genotypes. Multiple linear regression analysis demonstrated that the optimal pharmacogenetics-based model comprised age, body surface area, estimated glomerular filtration rate (eGFR), genotypes, vitamin K intake, aspartate aminotransferase levels, and alcohol intake. eGFR exercised a significant impact on the maintenance doses, as an increase in eGFR of 10 mL/min/1.73 m2 escalated the warfarin maintenance dose by 0.6 mg. Reduced eGFR was related to lower warfarin maintenance doses, independent of VKORC1 and CYP2C9 genotypes in Japanese patients.
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Affiliation(s)
- Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.I.); (K.F.); (K.W.); (S.K.); (K.N.)
- Correspondence:
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.I.); (K.F.); (K.W.); (S.K.); (K.N.)
| | - Kazuki Fukuma
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.I.); (K.F.); (K.W.); (S.K.); (K.N.)
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Osaka 564-8565, Japan;
| | - Kazuo Washida
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.I.); (K.F.); (K.W.); (S.K.); (K.N.)
| | - Shunsuke Kimura
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.I.); (K.F.); (K.W.); (S.K.); (K.N.)
| | - Akiko Kada
- Clinical Research and Development, National Cerebral and Cardiovascular Center, Suita, Osaka 564-8565, Japan;
| | - Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka 564-8565, Japan;
| | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka 564-8565, Japan;
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan; (M.I.); (K.F.); (K.W.); (S.K.); (K.N.)
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13
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Gao W, Li Z, Chen W, Zhang S. Performance Evaluation of Warfarin Dose Prediction Algorithms and Effects of Clinical Factors on Warfarin Dose in Chinese Patients. Ther Drug Monit 2021; 43:527-535. [PMID: 34250965 DOI: 10.1097/ftd.0000000000000880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The clinical utility of warfarin dose prediction algorithms remains controversial, our purpose is to evaluate the performance of warfarin dose prediction algorithms and the effects of clinical factors on warfarin dose in Chinese patients. METHODS Clinical data of 217 patients who received warfarin treatment were used to assess 6 warfarin dose prediction algorithms (OHNO, IWPC [International Warfarin Pharmacogenetics Consortium], HUANG, KIM, BRESS, and MIAO). The predicted dose (PD) was compared with the warfarin optimal dose (WOD, defined as the dose that maintains the international normalized ratio within the target range of 2.0-3.0). A multiple regression analysis with WOD as the dependent variable was performed to evaluate the effects of clinical factors on warfarin dose. RESULTS The mean absolute error analysis ranked the predictive accuracies of the algorithms as OHNO > IWPC > HUANG > KIM > BRESS > MIAO. Stratified analysis indicated that HUANG most accurately predicted that patients required lower WODs (≤3 mg/d), whereas OHNO was the most effective in predicting medium WODs (3-5 mg/d). KIM was effective in predicting high WODs (>5 mg/d). Multiple linear regression analysis showed that VKORC1 (rs9923231) and body mass index were significantly positively correlated with WOD, whereas concurrent atrial fibrillation status, CYP2C9*3 (rs1057910), and sex were significantly negatively correlated with WOD. CONCLUSIONS In Chinese patients, OHNO should be given priority during the prediction and selection of warfarin dose. When using OHNO to predict warfarin dose (≤3 mg/d or >5 mg/d), HUANG or KIM algorithms can provide precise predictions. At the same time, physicians should pay close attention to clinical factors, such as VKORC1 (rs9923231), concurrent atrial fibrillation status, CYP2C9*3 (rs1057910), body mass index, and sex, to improve warfarin dose adjustment strategies in Chinese patients.
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Affiliation(s)
- Weiqi Gao
- School of Pharmacy, Shanxi Medical University, Taiyuan, China; and
- Department of Pharmacy, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Zhihong Li
- Department of Pharmacy, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Weihong Chen
- Department of Pharmacy, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Shuqiu Zhang
- School of Pharmacy, Shanxi Medical University, Taiyuan, China; and
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Houtman E, Coutinho de Almeida R, Tuerlings M, Suchiman HED, Broekhuis D, Nelissen RGHH, Ramos YFM, van Meurs JBJ, Meulenbelt I. Characterization of dynamic changes in Matrix Gla Protein (MGP) gene expression as function of genetic risk alleles, osteoarthritis relevant stimuli, and the vitamin K inhibitor warfarin. Osteoarthritis Cartilage 2021; 29:1193-1202. [PMID: 33984465 DOI: 10.1016/j.joca.2021.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We here aimed to characterize changes of Matrix Gla Protein (MGP) expression in relation to its recently identified OA risk allele rs1800801-T in OA cartilage, subchondral bone and human ex vivo osteochondral explants subjected to OA related stimuli. Given that MGP function depends on vitamin K bioavailability, we studied the effect of frequently prescribed vitamin K antagonist warfarin. METHODS Differential (allelic) mRNA expression of MGP was analyzed using RNA-sequencing data of human OA cartilage and subchondral bone. Human osteochondral explants were used to study exposures to interleukin one beta (IL-1β; inflammation), triiodothyronine (T3; Hypertrophy), warfarin, or 65% mechanical stress (65%MS) as function of rs1800801 genotypes. RESULTS We confirmed that the MGP risk allele rs1800801-T was associated with lower expression and that MGP was significantly upregulated in lesioned as compared to preserved OA tissues, mainly in risk allele carriers, in both cartilage and subchondral bone. Moreover, MGP expression was downregulated in response to OA like triggers in cartilage and subchondral bone and this effect might be reduced in carriers of the rs1800801-T risk allele. Finally, warfarin treatment in cartilage increased COL10A1 and reduced SOX9 and MMP3 expression and in subchondral bone reduced COL1A1 and POSTN expression. DISCUSSION & CONCLUSIONS Our data highlights that the genetic risk allele lowers MGP expression and upon OA relevant triggers may hamper adequate dynamic changes in MGP expression, mainly in cartilage. The determined direct negative effect of warfarin on human explant cultures functionally underscores the previously found association between vitamin K deficiency and OA.
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Affiliation(s)
- E Houtman
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - R Coutinho de Almeida
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - M Tuerlings
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - H E D Suchiman
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - D Broekhuis
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Y F M Ramos
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - J B J van Meurs
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - I Meulenbelt
- Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.
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Xu Q, Zhang S, Wu C, Xiong Y, Niu J, Li F, Zhu J, Shen L, Zhu B, Xing Q, He L, Chen L, Li M, Li H, Ge J, Qin S. Genetic Associations With Stable Warfarin Dose Requirements in Han Chinese Patients. J Cardiovasc Pharmacol 2021; 78:e105-e111. [PMID: 33958549 DOI: 10.1097/fjc.0000000000001048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Warfarin is a commonly prescribed anticoagulant for valvular heart disease that plays an important role in clinical management to prevent thrombotic events. In this study, we aim to perform a comprehensive study to investigate the genetic biomarkers of stable warfarin dose in the Han Chinese population. We performed an integrative study on 211 Han Chinese patients with valvular heart disease. A total of 40 single nucleotide polymorphisms (SNPs) in 10 important genes (CYP2C9, VKORC1, ABCB1, CYP4F2, APOE, PROC, GGCX, EPHX1, CALU, and SETD1A) which are involved in the warfarin metabolic pathway and equilibrium of coagulation and anticoagulation were selected. We applied MassARRAY technology to genotype the 40 SNPs identified in these Han Chinese patients. Our results showed that 13 SNPs on 6 genes (CYP2C9, VKORC1, ABCB1, PROC, EPHX1, and SETD1A) were associated with the individual stable warfarin dose. Two VKORC1 SNPs (rs9934438 and rs2359612) were the strongest genetic factors determining warfarin dose requirements (P = 8 × 10-6 and 9 × 10-6, respectively). Rs4889599 in SETD1A was first reported to be associated with warfarin dose at a significant level of 0.001 in our study (Padjust = 0.040 after Bonferroni correction). We discovered that genetic variants in CYP2C9, VKORC1, ABCB1, PROC, EPHX1, and SETD1A may affect the stable warfarin dose requirement in Han Chinese patients with valvular disease. The discovery of these potential genetic markers will facilitate the development of advanced personalized anticoagulation therapy in Han Chinese patients.
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Affiliation(s)
- Qingqing Xu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Suli Zhang
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Chaoneng Wu
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuyu Xiong
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Jiamin Niu
- Laiwu People's Hospital, Shandong, China
| | | | - Jinhang Zhu
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Lu Shen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Bin Zhu
- Shanghai Baio Technology Co, Ltd Shanghai, China
| | | | - Lin He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Luan Chen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Mo Li
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Hua Li
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengying Qin
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
- The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
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Sridharan K, Al Banna R, Malalla Z, Husain A, Sater M, Jassim G, Otoom S. Influence of CYP2C9, VKORC1, and CYP4F2 polymorphisms on the pharmacodynamic parameters of warfarin: a cross-sectional study. Pharmacol Rep 2021; 73:1405-1417. [PMID: 33811620 DOI: 10.1007/s43440-021-00256-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Warfarin is the most commonly evaluated drug in pharmacogenetic-guided dosing studies. However, gaps remain regarding the influence of the genetic polymorphisms of CYP2C9, VKORC1, and CYP4F2 on specific pharmacodynamic parameters like the warfarin sensitivity index (WSI), prothrombin time international normalized ratio (PT-INR), and log-INR variability. METHODS A cross-sectional study was conducted in non-smoking adults receiving warfarin for at least 6 months. Their demographics, diagnoses, warfarin dosing regimen, concomitant drugs, PT-INR, and bleeding episodes were obtained. CYP2C9 (rs1057910-*3 and rs1799853-*2 alleles), CYP4F2 (rs2108622), and VKORC1 (rs9923231) polymorphisms were assessed using real-time polymerase chain reaction. Three genotype groups (I-III) were defined based on the combined genetic polymorphisms of CYP2C9 and VKORC1 from the FDA's recommendations. Key outcome measures included anticoagulation control, time spent in therapeutic range, stable warfarin dose, WSI, log-INR variability, and Warfarin Composite Measure (WCM). RESULTS The study recruited 236 patients; 75 (31.8%) carried a functional CYP2C9 variant allele, and, 143 (60.6%) had at least one T allele in CYP4F2 and 133 (56.4%) had at least one T allele in VKORC1. Groups' II and III CYP2C9 and VKORC1 genotypes were observed with reduced stable warfarin dose, increased WSI, higher log-INR variability, and increased bleeding risk. The presence of *2 or *3 allele in CYP2C9 was observed with reduced stable warfarin doses akin to the presence of T alleles in VKORC1; however, the doses increased with T alleles in CYP4F2. CONCLUSION The evaluated genetic polymorphisms significantly influenced all the pharmacodynamic parameters of warfarin. Evaluating CYP2C9, VKORC1, and CYP4F2 genetic polymorphisms prior to warfarin initiation is likely to optimize therapeutic response.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | - Rashed Al Banna
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
| | - Zainab Malalla
- Department of Medical Biochemistry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Aysha Husain
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
- RCSI-MUB, Manama, Kingdom of Bahrain
| | - Mai Sater
- Department of Medical Biochemistry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Ghufran Jassim
- Department of Family Medicine, RCSI-MUB, Manama, Kingdom of Bahrain
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Huang A, Lee K, Chan M, Mak K, Nishioka F, Gilbaugh A, Laguit K, Nespor C, Almond C, Kerner J. Getting the OK to Import Zero K MVI: Maintaining TTR in an Infant with SBS. Dig Dis Sci 2020; 65:3486-3492. [PMID: 32440747 DOI: 10.1007/s10620-020-06325-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Alice Huang
- Department of Pediatric Gastroenterology, Nutrition and Hepatology, Stanford Lucile Packard Children's Hospital, Palo Alto, USA.
| | - Kim Lee
- Department of Pharmacy, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Melanie Chan
- Department of Pharmacy, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Kwai Mak
- Department of Pharmacy, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Fred Nishioka
- Department of Pharmacy, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Andrea Gilbaugh
- Department of Pediatric Gastroenterology, Nutrition and Hepatology, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Kristine Laguit
- Department of Pediatric Gastroenterology, Nutrition and Hepatology, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Colleen Nespor
- Department of Pediatric Gastroenterology, Nutrition and Hepatology, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - Christopher Almond
- Department of Pediatric Cardiology, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
| | - John Kerner
- Department of Pediatric Gastroenterology, Nutrition and Hepatology, Stanford Lucile Packard Children's Hospital, Palo Alto, USA
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Abstract
Most of the prescribing and dispensing of medicines happens in primary care. Pharmacogenomics (PGx) is the study and clinical application of the role of genetic variation on drug response. Mounting evidence suggests PGx can improve the safety and/or efficacy of several medications commonly prescribed in primary care. However, implementation of PGx has generally been limited to a relatively few academic hospital centres, with little adoption in primary care. Despite this, many primary healthcare providers are optimistic about the role of PGx in their future practice. The increasing prevalence of direct-to-consumer genetic testing and primary care PGx studies herald the plausible gradual introduction of PGx into primary care and highlight the changes needed for optimal translation. In this article, the potential utility of PGx in primary care will be explored and on-going barriers to implementation discussed. The evidence base of several drug-gene pairs relevant to primary care will be outlined with a focus on antidepressants, codeine and tramadol, statins, clopidogrel, warfarin, metoprolol and allopurinol. This review is intended to provide both a general introduction to PGx with a more in-depth overview of elements relevant to primary care.
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Nakamura T, Shimizu H, Kawaguchi A. Drug-Drug Interactions of the Nonsteroidal Mineralocorticoid Receptor Antagonist Apararenone With Midazolam, Warfarin, and Digoxin: A Phase 1 Studies in Healthy Volunteers. Clin Ther 2020; 42:2171-2183.e4. [PMID: 33153727 DOI: 10.1016/j.clinthera.2020.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To characterize the clinical relevance of in vitro drug-drug interaction findings with apararenone (MT-3995), the effects of apararenone on the sensitive substrates of cytochrome P450 3A4 (midazolam) and 2C9 (warfarin), and P-glycoprotein (digoxin), were assessed through a series of studies conducted in healthy volunteers. METHODS Three studies were conducted in 56 healthy adults. Study 1 investigated the effects of the administration of apararenone with midazolam; apararenone was administered on days 2 (320 mg) and days 3-15 (20 mg/d), and midazolam 2 mg, on days 1 and 15. Study 2 investigated the effects of the administration of apararenone with warfarin; apararenone was administered on days 8-11 (40 mg/d) and days 12-27 (10 mg/d), and warfarin 25 mg, on days 1 and 21. Study 3 assessed the effects of the administration of apararenone with digoxin; apararenone was administered on days 11 (160 mg) and days 12-28 (10 mg/d), and digoxin 0.5 mg, on days 1 and 24. Pharmacokinetic parameters included Cmax, AUC0-t, and AUC0-∞. The safety profile was evaluated based on adverse events from spontaneous reports and clinical findings. FINDINGS After the administration of midazolam together with apararenone, compared with midazolam alone, the midazolam ± apararenone treatment ratios (90% CIs) of the geometric least squares (LS) mean Cmax, AUC0-t, and AUC0-∞ values were 1.263 (1.147-1.392), 1.342 (1.220-1.477), and 1.370 (1.225-1.534), respectively. After the administration of warfarin ± apararenone, the R-warfarin ± apararenone treatment ratios (90% CIs) of the geometric LS mean Cmax, AUC0-t, and AUC0-∞ values were 1.008 (0.934-1.089), 1.078 (1.029-1.129), and 1.110 (1.056-1.166). Corresponding values for S-warfarin were 1.025 (0.941-1.117), 1.024 (0.979-1.071), and 1.031 (0.984-1.080). After the administration of digoxin ± apararenone, the digoxin ± apararenone treatment ratios (90% CIs) of the geometric LS mean Cmax, AUC0-t, and AUC0-∞ values were 0.929 (0.789-1.093), 0.894 (0.797-1.033), and 0.887 (0.805-0.977), respectively. Treatment-emergent adverse events were generally of mild to moderate intensity, and no serious adverse events of any kind were reported. IMPLICATIONS The findings from this analysis of data from healthy volunteers suggest minimal risk for potential drug-drug interactions between apararenone and other drugs that are likely to be used concurrently in patients. ClinicalTrials.gov identifier: NCT02531568.
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Affiliation(s)
- Tadakatsu Nakamura
- Ikuyaku Integrated Value Development Division, Data Science Department, Clinical Pharmacology Group, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan.
| | - Hidetoshi Shimizu
- Ikuyaku Integrated Value Development Division, Data Science Department, Clinical Pharmacology Group, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Atsuhiro Kawaguchi
- Ikuyaku Integrated Value Development Division, Data Science Department, Clinical Pharmacology Group, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
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Zhang F, Huang J, He RJ, Wang L, Huo PC, Guan XQ, Fang SQ, Xiang YW, Jia SN, Ge GB. Herb-drug interaction between Styrax and warfarin: Molecular basis and mechanism. Phytomedicine 2020; 77:153287. [PMID: 32739573 DOI: 10.1016/j.phymed.2020.153287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Styrax, one of the most famous folk medicines, has been frequently used for the treatment of cardiovascular diseases and skin problems in Asia and Africa. It is unclear whether Styrax or Styrax-related herbal medicines may trigger clinically relevant herb-drug interactions. PURPOSE This study was carried out to investigate the inhibitory effects of Styrax on human cytochrome P450 enzymes (CYPs) and to clarify whether this herb may modulate the pharmacokinetic behavior of the CYP-substrate drug warfarin when co-administered. STUDY DESIGN The inhibitory effects of Styrax on CYPs were assayed in human liver microsomes (HLM), while the pharmacokinetic interactions between Styrax and warfarin were investigated in rats. The bioactive constituents in Styrax with strong CYP3A inhibitory activity were identified and their inhibitory mechanisms were carefully investigated. METHODS The inhibitory effects of Styrax on human CYPs were assayed in vitro, while the pharmacokinetic interactions between Styrax and warfarin were studied in rats. Fingerprinting analysis of Styrax coupled with LC-TOF-MS/MS profiling and CYP inhibition assays were used to identify the constituents with strong CYP3A inhibitory activity. The inhibitory mechanism of oleanonic acid (the most potent CYP3A inhibitor occurring in Styrax) against CYP3A4 was investigated by a panel of inhibition kinetics analyses and in silico analysis. RESULTS In vitro assays demonstrated that Styrax extract strongly inhibited human CYP3A and moderately inhibited six other tested human CYPs, as well as potently inhibited warfarin 10-hydroxylation in liver microsomes from both humans and rats. In vivo assays demonstrated that compared with warfarin given individually in rats, Styrax (100 mg/kg) significantly prolonged the plasma half-life of warfarin by 2.3-fold and increased the AUC(0-inf) of warfarin by 2.7-fold when this herb was co-administrated with warfarin (2 mg/kg) in rats. Two LC fractions were found with strong CYP3A inhibitory activity and the major constituents in these fractions were characterized by LC-TOF-MS/MS. Five pentacyclic triterpenoid acids (including epibetulinic acid, betulinic acid, betulonic acid, oleanonic acid and maslinic acid) present in Styrax were potent CYP3A inhibitors, and oleanonic acid was a competitive inhibitor against CYP3A-mediated testosterone 6β-hydroxylation. CONCLUSION Styrax and the pentacyclic triterpenoid acids occurring in this herb strongly modulate the pharmacokinetic behavior of warfarin via inhibition of CYP3A.
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Affiliation(s)
- Feng Zhang
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jian Huang
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Pharmacology and Toxicology Division, Shanghai Institute of Food and Drug Control, Shanghai, China
| | - Rong-Jing He
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lu Wang
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Peng-Chao Huo
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiao-Qing Guan
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Sheng-Quan Fang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200473, China
| | - Yan-Wei Xiang
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shou-Ning Jia
- Qinghai Hospital of Traditional Chinese Medicine, Xining, China
| | - Guang-Bo Ge
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200473, China.
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Qiu H, Jin L, Chen J, Shi M, Shi F, Wang M, Li D, Xu X, Su X, Yin X, Li W, Zhou X, Linhardt RJ, Wang Z, Chi L, Zhang Q. Comprehensive Glycomic Analysis Reveals That Human Serum Albumin Glycation Specifically Affects the Pharmacokinetics and Efficacy of Different Anticoagulant Drugs in Diabetes. Diabetes 2020; 69:760-770. [PMID: 31974145 DOI: 10.2337/db19-0738] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 01/12/2020] [Indexed: 12/21/2022]
Abstract
Long-term hyperglycemia in patients with diabetes leads to human serum albumin (HSA) glycation, which may impair HSA function as a transport protein and affect the therapeutic efficacy of anticoagulants in patients with diabetes. In this study, a novel mass spectrometry approach was developed to reveal the differences in the profiles of HSA glycation sites between patients with diabetes and healthy subjects. K199 was the glycation site most significantly changed in patients with diabetes, contributing to different interactions of glycated HSA and normal HSA with two types of anticoagulant drugs, heparin and warfarin. An in vitro experiment showed that the binding affinity to warfarin became stronger when HSA was glycated, while HSA binding to heparin was not significantly influenced by glycation. A pharmacokinetic study showed a decreased level of free warfarin in the plasma of diabetic rats. A preliminary retrospective clinical study also revealed that there was a statistically significant difference in the anticoagulant efficacy between patients with diabetes and patients without diabetes who had been treated with warfarin. Our work suggests that larger studies are needed to provide additional specific guidance for patients with diabetes when they are administered anticoagulant drugs or drugs for treating other chronic diseases.
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Affiliation(s)
- Hongyan Qiu
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Lan Jin
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jian Chen
- Qingdao Municipal Center for Disease Control and Prevention, Qingdao, Shandong, China
| | - Min Shi
- Jinan Center for Food and Drug Control, Jinan, Shandong, China
| | - Feng Shi
- Scientific Research Division, Shandong Institute for Food and Drug Control, Jinan, Shandong, China
| | - Mansen Wang
- Medical Data Research Center, Providence Health & Services, Portland, OR
| | - Daoyuan Li
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Xiaohui Xu
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Xinhuan Su
- Division of Endocrinology and Metabolism, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Xianlun Yin
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Wenhua Li
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Xiaoming Zhou
- Division of Endocrinology and Metabolism, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Robert J Linhardt
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY
| | - Zhe Wang
- Division of Endocrinology and Metabolism, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Lianli Chi
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Qunye Zhang
- National Glycoengineering Research Center, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, and The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
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Heinig R, Gerisch M, Bairlein M, Nagelschmitz J, Loewen S. Results from Drug-Drug Interaction Studies In Vitro and In Vivo Investigating the Effect of Finerenone on the Pharmacokinetics of Comedications. Eur J Drug Metab Pharmacokinet 2020; 45:433-444. [PMID: 32125665 DOI: 10.1007/s13318-020-00610-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES In vivo studies were performed with the novel, selective, non-steroidal mineralocorticoid receptor antagonist finerenone to assess the relevance of inductive and/or inhibitory effects on cytochrome P450 (CYP) enzymes observed in vitro. METHODS CYP isoenzyme-specific substrates were incubated in vitro with finerenone or its metabolites to investigate reversible and irreversible inhibitory as well as inductive potential. Three crossover studies in healthy male volunteers investigated the effects of finerenone (20 mg orally) on the pharmacokinetics of the index substrates midazolam (CYP3A4, n = 30), repaglinide (CYP2C8, n = 28) and warfarin (CYP2C9, n = 24). RESULTS Finerenone caused direct inhibitory effects on CYP activities in vitro in the rank order CYP2C8, CYP1A1 > CYP3A4 > CYP2C9 and CYP2C19, but not on other major CYP isoforms. Moreover, irreversible inhibition of CYP3A4 was observed. The major metabolites of finerenone demonstrated minor reversible inhibition of CYP1A1, CYP2C9 and CYP3A4 with no hint of time-dependent inhibition of any CYP isoform. Calculations from in vitro data according to regulatory guidelines suggested likely inhibition of CYP2C8 and CYP3A4 in vivo, whereas this was not the case for CYP1A1, CYP2C9 and CYP2C19. Furthermore, finerenone and three of its metabolites were inducers of CYP3A4 in vitro with predicted weak-to-moderate in vivo relevance. Studies in healthy volunteers, prompted by these results, demonstrated no effect of finerenone on CYP isoenzymes for which in vitro data had indicated potential inhibition or induction. CONCLUSION Administration of finerenone 20 mg once daily confers no risk of clinically relevant drug-drug interactions with substrates of cytochrome P450 enzymes.
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Affiliation(s)
- Roland Heinig
- Bayer AG, Research and Development, Pharmaceuticals, Clinical Sciences, Wuppertal, Germany.
| | - Michael Gerisch
- Bayer AG, Research and Development, Pharmaceuticals, DMPK, Wuppertal, Germany
| | - Michaela Bairlein
- Bayer AG, Research and Development, Pharmaceuticals, DMPK, Wuppertal, Germany
| | - Johannes Nagelschmitz
- Bayer AG, Research and Development, Pharmaceuticals, Clinical Sciences, Wuppertal, Germany
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Raghav D, Mahanty S, Rathinasamy K. Characterizing the interactions of the antipsychotic drug trifluoperazine with bovine serum albumin: Probing the drug-protein and drug-drug interactions using multi-spectroscopic approaches. Spectrochim Acta A Mol Biomol Spectrosc 2020; 226:117584. [PMID: 31698317 DOI: 10.1016/j.saa.2019.117584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/16/2019] [Accepted: 09/29/2019] [Indexed: 06/10/2023]
Abstract
Trifluoperazine is a potent antipsychotic drug used in the treatment of neurological disorders. The usage of trifluoperazine is often found to be associated with more adverse side effects as compared to other low-potency antipsychotic agents. Plasma proteins play an inevitable role in determining the pharmacokinetic properties of a drug. Hence, this study was conducted with an aim to characterize the interactions of trifluoperazine with bovine serum albumin and determine the influence of other small molecules on its interaction with serum albumin. Trifluoperazine bound to BSA at two independent sites with Kd values of 9.5 and 172.6 μM. Förster resonance energy transfer and computational docking analysis revealed that both the binding sites of trifluoperazine were located closer to TRP 213 in subdomain IIA of BSA. Evaluation of trifluoperazine-BSA interactions at three different temperatures indicated that there was a stable complex formation between the two molecules at the ground state and that the static quenching mechanism was predominant behind these interactions. Binding studies in the presence of pharmaceutically relevant drugs indicated that warfarin, paracetamol, and caffeine negatively influenced the binding of trifluoperazine on BSA. Lastly, Fourier transformed infrared spectroscopy and circular dichroism spectroscopy indicated that the binding of trifluoperazine induced a conformational change by reducing the α-helical content of BSA. The study implicates that the small molecules which prefer binding to the Sudlow site I of BSA might compete with trifluoperazine for its binding site thereby increasing the concentration of free trifluoperazine in the plasma which could lead to adverse side effects in patients.
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Affiliation(s)
- Darpan Raghav
- School of Biotechnology, National Institute of Technology Calicut, Calicut, Kerala, India
| | - Susobhan Mahanty
- School of Biotechnology, National Institute of Technology Calicut, Calicut, Kerala, India
| | - Krishnan Rathinasamy
- School of Biotechnology, National Institute of Technology Calicut, Calicut, Kerala, India.
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Mohamed MF, Feng T, Enejosa JV, Fisniku O, Othman AA. Effects of Upadacitinib Coadministration on the Pharmacokinetics of Sensitive Cytochrome P450 Probe Substrates: A Study With the Modified Cooperstown 5+1 Cocktail. J Clin Pharmacol 2020; 60:86-95. [PMID: 31378969 PMCID: PMC6972567 DOI: 10.1002/jcph.1496] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
The aim of this study was to characterize the effects of upadacitinib, a Janus kinase 1 inhibitor, on in vivo activity of different cytochrome P450 (CYP) enzymes using a cocktail approach. Healthy subjects (n = 20) received single oral doses of the modified Cooperstown 5+1 cocktail drugs (midazolam [CYP3A], caffeine [CYP1A2], warfarin + vitamin K [CYP2C9], omeprazole [CYP2C19], and dextromethorphan [CYP2D6]) without upadacitinib and on day 11 (midazolam) or 12 (all other probes) of a 15-day regimen of upadacitinib 30 mg once daily (extended-release formulation). Serial blood samples and 12-hour urine samples were collected for assays of the probe substrates and select metabolites. The ratio (90%CI) of area under the plasma concentration-time curve from time 0 to infinity (AUCinf ) central values when the cocktail drugs were administered with upadacitinib relative to when administered alone were 0.74 (0.68-0.80) for midazolam, 1.22 (1.15-1.29) for caffeine, 1.11 (1.07-1.15) for S-warfarin, 1.07 (0.95-1.22) for dextromethorphan, and 0.82 (0.72-0.94) for omeprazole. The ratio (90%CI) was 1.09 (1.00-1.19) for 5-hydroxy-omeprazole to omeprazole AUCinf ratio and 1.17 (0.97-1.41) for dextromethorphan to dextrorphan 12-hour molar urinary ratio. Upadacitinib 30 mg once daily (a dose that is twice the optimal dose in rheumatoid arthritis based on phase 3 results) has a limited effect on CYP3A activity (26% decrease in exposure of midazolam, a sensitive CYP3A substrate) and no relevant effects on CYP1A2, CYP2C9, CYP2C19, or CYP2D6 activity in vivo. No clinically relevant changes in plasma exposures are expected for drugs that are substrates for the evaluated CYP enzymes when coadministered with upadacitinib.
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Affiliation(s)
| | - Tian Feng
- Department of StatisticsAbbVie Inc.North ChicagoIllinoisUSA
| | | | - Ogert Fisniku
- Regulated BioanalysisAbbVie Inc.North ChicagoIllinoisUSA
| | - Ahmed A. Othman
- Clinical Pharmacology and PharmacometricsAbbVie Inc.North ChicagoIllinoisUSA
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Leopold LF, Rugină D, Oprea I, Diaconeasa Z, Leopold N, Suciu M, Coman V, Vodnar DC, Pintea A, Coman C. Warfarin-Capped Gold Nanoparticles: Synthesis, Cytotoxicity, and Cellular Uptake. Molecules 2019; 24:molecules24224145. [PMID: 31731755 PMCID: PMC6891392 DOI: 10.3390/molecules24224145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/25/2019] [Accepted: 11/13/2019] [Indexed: 11/25/2022] Open
Abstract
Currently, research studies on nanoparticle cytotoxicity, uptake or internalization into the body’s cells are of great interest for the improvement of diagnostic and therapeutic applications. We report here the synthesis and characterization of very stable novel warfarin-capped gold nanoparticles with an average diameter of 54 ± 10 nm which were prepared using sodium warfarin as a reducing agent. The nanoparticles were tested in terms of cytotoxicity and cellular internalization in vitro on two cell lines: normal lung fibroblast HFL-1 and human retinal pigment epithelial D407 cells. Our results showed that the normal lung fibroblast HFL-1 cells were more sensitive to the nanoparticle treatment compared to the human retinal pigment epithelial D407 cells. Moreover, any signs of potential cytotoxicity occurred during the first 24 h of treatment, the cellular viability remaining largely unchanged for longer exposure times. Transmission electron microscopy and dark field hyperspectral imaging revealed that the nanoparticles were effectively delivered and released to the HFL-1 and D407 cells’ cytoplasm. Our results provide valuable information to further investigate sodium warfarin-capped gold nanoparticles for possible biological applications.
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Affiliation(s)
- Loredana Florina Leopold
- Faculty of Food Science and Technology, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (L.F.L.); (I.O.); (Z.D.); (D.C.V.)
| | - Dumitriţa Rugină
- Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (D.R.); (A.P.)
| | - Ioana Oprea
- Faculty of Food Science and Technology, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (L.F.L.); (I.O.); (Z.D.); (D.C.V.)
| | - Zorița Diaconeasa
- Faculty of Food Science and Technology, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (L.F.L.); (I.O.); (Z.D.); (D.C.V.)
| | - Nicolae Leopold
- Faculty of Physics, Babeș-Bolyai University, Kogălniceanu 1, 400084 Cluj-Napoca, Romania;
| | - Maria Suciu
- Electron Microscopy Center, Faculty of Biology and Geology, Babeș-Bolyai University, Clinicilor 5-7, 400006 Cluj-Napoca, Romania;
- National Institute for Research and Development of Isotopic and Molecular Technologies, Donath 67-103, 400293 Cluj-Napoca, Romania
| | - Vasile Coman
- Institute of Life Sciences, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania;
| | - Dan Cristian Vodnar
- Faculty of Food Science and Technology, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (L.F.L.); (I.O.); (Z.D.); (D.C.V.)
| | - Adela Pintea
- Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (D.R.); (A.P.)
| | - Cristina Coman
- Faculty of Food Science and Technology, University of Agricultural Sciences and Veterinary Medicine, Mănăștur 3-5, 400372 Cluj-Napoca, Romania; (L.F.L.); (I.O.); (Z.D.); (D.C.V.)
- Correspondence: ; Tel.: +40-746-959-157
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Qayyum A, Najmi MH, Raza SI, Rajput TA, Naveed AK. Relationship of S/R warfarin ratio with CYP2C9 genotypes in Pakistani population. Pak J Pharm Sci 2019; 32:1581-1588. [PMID: 31608877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Warfarin is administered as a racemic preparation of R- and S-enantiomers. S-warfarin is more potent than R-warfarin, so changes in blood levels of S-warfarin affect the anticoagulant response. This study was carried out to determine the effect of CYP2C9*2 and CYP2C9*3 polymorphisms on S/R warfarin ratio. A single blood sample was collected 12-16 hours after drug administration from 170 stable patients fulfilling the criteria. Genotyping of the CYP2C9 polymorphisms was done by polymerase chain reaction-restriction fragment length polymorphism assay. S- and R-warfarin enantiomers extraction from plasma was accomplished by a validated HPLC method. The concentration of S-warfarin was significantly different among CYP2C9 genotypes (p =0.018) whereas there was no effect on R-warfarin (p =0.134). There was statistically significant effect of different CYP2C9 genotypes on S/R warfarin ratio (p=0.000). It is concluded that CYP2C9 polymorphisms influence CYP2C9 enzymatic activity in turn affecting S-warfari levels but not R-warfarin, thus leading to different S/R warfarin enantiomers ratio among different CYP2C9 genotypes.
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Affiliation(s)
- Aisha Qayyum
- Department of Pharmacology, Fazaia Medical College, Air University, Islamabad, Pakistan
| | - Muzammil Hasan Najmi
- Department of Pharmacology, Foundation University Medical College, Islamabad, Pakistan
| | | | - Tausif Ahmad Rajput
- Shifa College of Pharmaceutical Sciences, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Abdul Khaliq Naveed
- Department of Biochemistry, Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan
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Leclerc J, Blais C, Rochette L, Hamel D, Guénette L, Poirier P. Trends in Hospital Visits for Generic and Brand-Name Warfarin Users in Québec, Canada: A Population-Based Time Series Analysis. Am J Cardiovasc Drugs 2019; 19:287-297. [PMID: 30471054 DOI: 10.1007/s40256-018-0309-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Federal standards authorize the commercialization of generic medicines after bioequivalence versus the brand-name originator has been demonstrated. For drugs with narrow therapeutic indexes, such as warfarin, the accepted difference in bioavailability is ≤ 10%. No systematic pharmacovigilance studies are conducted once generics become available. OBJECTIVE We aimed to assess the impact of the arrival of generic warfarin on hospital visit trends (hospital admissions or emergency room consultations) in warfarin users. METHODS This was an observational interrupted time series analysis (2 January 1996 to 1 January 2016). Using the Québec Integrated Chronic Disease Surveillance System, we included all patients who were aged ≥ 66 years, publicly covered and using brand-name or generic warfarin (N = 280,158). We estimated rates of hospital visits in 6-month periods, 5 years before and up to 15 years after the arrival of generic warfarin. Periods before and after were compared using segmented regression models for all users along with exploratory (generic vs. brand name)/subgroup analyses (cardiovascular comorbidities and socioeconomic status). RESULTS Generic warfarin arrived on the market on 2 January 2001. Over the 20-year period of the study, the mean rate of hospital visits was 113 for 100 brand-name or generic users per 6-month period and was similar before and after the arrival of the generics. Up to 15 years after the arrival of the generics, the rates of hospital visits were 10% higher for generic than for brand-name users, which was confirmed by subgroup analyses. CONCLUSIONS Overall, we observed no impact on hospital visits after the arrival of generic warfarin in all the population treated with any type of warfarin. However, a higher crude rate of hospital visits among generic users than brand-name users remains to be validated using a different methodology and specific outcomes.
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Affiliation(s)
- Jacinthe Leclerc
- Institut National de Santé Publique du Québec, Bureau D'information et D'études en Santé des Populations, Quebec, QC, Canada
- Nursing Department, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Claudia Blais
- Institut National de Santé Publique du Québec, Bureau D'information et D'études en Santé des Populations, Quebec, QC, Canada
- Faculty of Pharmacy, Université Laval, Quebec, QC, Canada
| | - Louis Rochette
- Institut National de Santé Publique du Québec, Bureau D'information et D'études en Santé des Populations, Quebec, QC, Canada
| | - Denis Hamel
- Institut National de Santé Publique du Québec, Bureau D'information et D'études en Santé des Populations, Quebec, QC, Canada
| | - Line Guénette
- Faculty of Pharmacy, Université Laval, Quebec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, CHU de Québec-Université Laval Research Center, Quebec, QC, Canada
| | - Paul Poirier
- Faculty of Pharmacy, Université Laval, Quebec, QC, Canada.
- Research Center, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Quebec, G1V 4G5, QC, Canada.
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Ikarashi N, Nagoya C, Kon R, Kitaoka S, Kajiwara S, Saito M, Kawabata A, Ochiai W, Sugiyama K. Changes in the Expression of Aquaporin-3 in the Gastrointestinal Tract Affect Drug Absorption. Int J Mol Sci 2019; 20:ijms20071559. [PMID: 30925715 PMCID: PMC6479729 DOI: 10.3390/ijms20071559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 02/07/2023] Open
Abstract
Aquaporin-3 (AQP3) plays an important role in water transport in the gastrointestinal (GI) tract. In this study, we conducted a Caco-2 cell permeability assay to examine how changes in the expression and function of AQP3 affect the rate at which a drug is absorbed via passive transport in the GI tract. When the function of AQP3 was inhibited by mercuric chloride or phloretin, there was no change in warfarin permeability. In contrast, when the expression of AQP3 protein was decreased by prostaglandin E₂ (PGE₂) treatment, warfarin permeability increased to approximately twice the control level, and membrane fluidity increased by 15%. In addition, warfarin permeability increased to an extent comparable to that after PGE₂ treatment when cell membrane fluidity was increased by 10% via boric acid/EDTA treatment. These findings suggest the possibility that the increased drug absorption under decreased AQP3 expression was attributable to increased membrane fluidity. The results of this study demonstrate that the rate of water transport has little effect on drug absorption. However, our findings also indicate that although AQP3 and other similar transmembrane proteins do not themselves transport drugs, changes in their expression levels can cause changes in cell membrane fluidity, thus affecting drug absorption rates.
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Affiliation(s)
- Nobutomo Ikarashi
- Department of Biomolecular Pharmacology, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Chika Nagoya
- Department of Clinical Pharmacokinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Risako Kon
- Department of Biomolecular Pharmacology, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Satoshi Kitaoka
- Department of Clinical Pharmacokinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Sayuri Kajiwara
- Department of Clinical Pharmacokinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Masayo Saito
- Department of Clinical Pharmacokinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Akane Kawabata
- Department of Clinical Pharmacokinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Wataru Ochiai
- Department of Clinical Pharmacokinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
| | - Kiyoshi Sugiyama
- Department of Functional Molecular Kinetics, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan.
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Weber J, Olyaei A, Shatzel J. The efficacy and safety of direct oral anticoagulants in patients with chronic renal insufficiency: A review of the literature. Eur J Haematol 2019; 102:312-318. [PMID: 30592337 DOI: 10.1111/ejh.13208] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 01/15/2023]
Abstract
Direct oral anticoagulants (DOACs) have been shown to be superior to vitamin K antagonists (VKAs) in regards to safety and efficacy in numerous clinical trials and are now the preferred oral anticoagulant by multiple professional societies. However, patients with significant levels of organ dysfunction were excluded from all major clinical trials, leaving the clinical benefit in these subsets uncertain. Patients with chronic kidney disease (CKD) specifically often require anticoagulation for acute or long-term indications such as venous thromboembolism, atrial fibrillation, or mechanical heart valves. The efficacy and safety of anticoagulation in patients with renal failure is less certain, however, particularly with DOACs which have altered pharmacokinetics in patients with renal failure and limited observational data on their use in this population. In this review, we compile the most up to date data on the DOAC use in patients with CKD. DOAC use in patients with ESRD and advanced CKD is increasing despite the presence of a clear benefit, and with the potential for increased risk of bleeding compared to warfarin. Apixaban has the greatest amount of outcomes research supporting its use over warfarin in this patient population; however, further research on DOAC safety and efficacy in those with advanced CKD is still needed.
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Affiliation(s)
- Jacob Weber
- The Division of Hematology & Oncology, School of Medicine, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Ali Olyaei
- Department of Medicine, Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, Oregon
| | - Joseph Shatzel
- The Division of Hematology & Oncology, School of Medicine, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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Alnaqeeb M, Mansor KA, Mallah EM, Ghanim BY, Idkaidek N, Qinna NA. Critical pharmacokinetic and pharmacodynamic drug-herb interactions in rats between warfarin and pomegranate peel or guava leaves extracts. BMC Complement Altern Med 2019; 19:29. [PMID: 30678660 PMCID: PMC6344987 DOI: 10.1186/s12906-019-2436-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND In-depth information of potential drug-herb interactions between warfarin and herbal compounds with suspected anticoagulant blood thinning effects is needed to raise caution of concomitant administration. The current study aimed to investigate the impact of co-administration of pomegranate peel and guava leaves extracts, including their quality markers namely; ellagic acid and quercetin, respectively, on warfarin's in vivo dynamic activity and pharmacokinetic actions, in addition to potential in vitro cytochrome P450 enzymes (CYP) inhibition. METHODS Influence of mentioned extracts and their key constituents on warfarin pharmacodynamic and kinetic actions and CYP activity were evaluated. The pharmacodynamic interactions were studied in Sprague Dawley rats through prothrombin time (PT) and International Normalized Ratio (INR) measurements, while pharmacokinetic interactions were detected in vivo using a validated HPLC method. Furthermore, potential involvement in CYP inhibition was also investigated in vitro on isolated primary rat hepatocytes. RESULTS Preparations of pomegranate peel guava leaf extract, ellagic acid and quercetin in combination with warfarin were found to exert further significant increase on PT and INR values (p < 0.01) than when used alone (p < 0.05). Pomegranate peel extract showed insignificant effects on warfarin pharmacokinetics (p > 0.05), however, its constituent, namely, ellagic acid significantly increased warfarin Cmax (p < 0.05). Guava leaves extract and quercetin resulted in significant increase in warfarin Cmax when compared to control (p < 0.01). Furthermore, guava leaves extract showed a significant effect on changing the AUC, CL and Vz. Significant reduction in CYP2C8, 2C9, and 3A4 was seen upon concomitant use of warfarin with ellagic acid, guava leaves and quercetin, unlike pomegranate that insignificantly affected CYP activities. CONCLUSION All combinations enhanced the anticoagulant activity of warfarin as the results of in vivo and in vitro studies were consistent. The current investigation confirmed serious drug herb interactions between warfarin and pomegranate peel or guava leaf extracts. Such results might conclude a high risk of bleeding from the co-administration of the investigated herbal drugs with warfarin therapy. In addition, the results raise attention to the blood-thinning effects of pomegranate peel and guava leaves when used alone.
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Affiliation(s)
- Maisa Alnaqeeb
- Department of Pharmacology and Biomedical Sciences, Faculty of Pharmacy and Medical Sciences, University of Petra, Airport Road, P.O. Box 961343, Amman, Jordan
| | - Kenza A. Mansor
- Department of Pharmaceutical Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan
| | - Eyad M. Mallah
- Department of Pharmaceutical Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan
| | - Bayan Y. Ghanim
- University of Petra Pharmaceutical Center (UPPC), University of Petra, Amman, Jordan
| | - Nasir Idkaidek
- University of Petra Pharmaceutical Center (UPPC), University of Petra, Amman, Jordan
| | - Nidal A. Qinna
- Department of Pharmacology and Biomedical Sciences, Faculty of Pharmacy and Medical Sciences, University of Petra, Airport Road, P.O. Box 961343, Amman, Jordan
- University of Petra Pharmaceutical Center (UPPC), University of Petra, Amman, Jordan
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Zhang X, Zhang X, Wang X, Zhao M. Influence of andrographolide on the pharmacokinetics of warfarin in rats. Pharm Biol 2018; 56:351-356. [PMID: 29983086 PMCID: PMC6130436 DOI: 10.1080/13880209.2018.1478431] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/26/2018] [Accepted: 05/15/2018] [Indexed: 05/27/2023]
Abstract
CONTEXT Andrographolide and warfarin are often used together in clinics in China. However, the herb-drug interaction between andrographolide and warfarin is still unknown. OBJECTIVE This study investigates the herb-drug interaction between andrographolide and warfarin in vivo and in vitro. MATERIALS AND METHODS A sensitive and reliable LC-MS/MS method was developed for the determination of warfarin in male Sprague-Dawley rats plasma, and then the pharmacokinetics of orally administered warfarin (0.5 mg/kg) with or without andrographolide (30 mg/kg/day for 7 days) pretreatment was investigated. In addition, Sprague-Dawley rat liver microsomes incubation systems were used to support the in vivo pharmacokinetic data and investigate its potential mechanism. RESULTS The method validation results showed that a sensitive and reliable LC-MS/MS method was developed for the determination of warfarin in rat plasma samples. The pharmacokinetic results indicated that co-administration of andrographolide could increase the systemic exposure of warfarin significantly, including area under the curve (118.92 ± 18.08 vs. 60.58 ± 9.46 μg × h/mL), maximum plasma concentration (3.32 ± 0.41 vs. 2.35 ± 0.25 μg/mL) and t1/2 (22.73 ± 3.28 vs. 14.27 ± 2.67 h). Additionally, the metabolic stability of warfarin increased from 23.5 ± 4.7 to 38.7 ± 6.1 min with the pretreatment of andrographolide, and the difference was significant (p < 0.05). DISCUSSION AND CONCLUSION In conclusion, andrographolide could increase the systemic exposure of warfarin in rats when andrographolide and warfarin were co-administered, and possibly by slowing down the metabolism of warfarin in rat liver by inhibiting the activity of CYP3A4 or CYP2C9.
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Affiliation(s)
- Xiaoli Zhang
- Department of Nephrology, Yidu Central Hospital of Weifang, Shandong, China
- Department of Nursing, Yidu Central Hospital of Weifang, Shandong, China
| | - Xiaosu Zhang
- Department of Nephrology, Yidu Central Hospital of Weifang, Shandong, China
| | - Xiaocui Wang
- Department of Nephrology, Yidu Central Hospital of Weifang, Shandong, China
| | - Meijun Zhao
- Department of Nursing, Yidu Central Hospital of Weifang, Shandong, China
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Škarić-Jurić T, Tomas Ž, Zajc Petranović M, Božina N, Smolej Narančić N, Janićijević B, Salihović MP. Characterization of ADME genes variation in Roma and 20 populations worldwide. PLoS One 2018; 13:e0207671. [PMID: 30452466 PMCID: PMC6242375 DOI: 10.1371/journal.pone.0207671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
The products of the polymorphic ADME genes are involved in Absorption, Distribution, Metabolism, and Excretion of drugs. The pharmacogenetic data have been studied extensively due to their clinical importance in the appropriate drug prescription, but such data from the isolated populations are rather scarce. We analyzed the distribution of 95 polymorphisms in 31 core ADME genes in 20 populations worldwide and in newly genotyped samples from the Roma (Gypsy) population living in Croatia. Global distribution of ADME core gene loci differentiated three major clusters; (1) African, (2) East Asian, and (3) joint European, South Asian and South American cluster. The SLCO1B3 (rs4149117) and CYP3A4 (rs2242480) genes differentiated at the highest level the African group of populations, while NAT2 gene loci (rs1208, rs1801280, and rs1799929) and VKORC1 (rs9923231) differentiated East Asian populations. The VKORC1 rs9923231 was among the investigated loci the one with the largest global minor allele frequency (MAF) range; its MAF ranged from 0.027 in Nigeria to 0.924 in Han Chinese. The distribution of the investigated gene loci positions Roma population within the joined European and South Asian clusters, suggesting that their ADME gene pool is a combination of ancestral (Indian) and more recent (European) surrounding, as it was already implied by other genetic markers. However, when compared to the populations worldwide, the Croatian Roma have extreme MAF values in 10 out of the 95 investigated ADME core gene loci. Among loci which have extraordinary MAFs in Roma population two have strong proof of clinical importance: rs1799853 (CYP2C9) for warfarin dosage, and rs12248560 (CYP2C19) for clopidogrel dosage, efficacy and toxicity. This finding confirms the importance of taking the Roma as well as the other isolated populations`genetic profiles into account in pharmaco-therapeutic practice.
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Affiliation(s)
| | - Željka Tomas
- Institute for Anthropological Research, Zagreb, Croatia
| | | | - Nada Božina
- Department for Pharmacogenomics and Therapy Individualization, University Hospital Center Zagreb, Department of Pharmacology, University of Zagreb School of Medicine, Zagreb, Croatia
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Al-Sallami H, Loke SK. Learning a complex dose-response relationship with the computer simulation CoaguSim. Curr Pharm Teach Learn 2018; 10:1406-1413. [PMID: 30527370 DOI: 10.1016/j.cptl.2018.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 05/03/2018] [Accepted: 07/09/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND PURPOSE Coagulation is a complex physiological process that includes numerous feedback and feedforward reactions. Learning about coagulation and the use of anticoagulants is complicated by the dynamic and non-linear nature of the processes involved. The purpose of this study was to implement and evaluate the effects of a computer simulation-enabled workshop on students' understanding of the time course of warfarin effect. EDUCATIONAL ACTIVITY AND SETTING A computer simulation of coagulation (CoaguSim) was developed to support an undergraduate pharmacy therapeutics workshop. Workshop activities were designed to allow students to generate and test their own hypotheses via CoaguSim based on a case scenario involving treatment with the anti-clotting drug warfarin. FINDINGS One hundred and fifteen final year bachelor of pharmacy (BPharm) students participated in the case study. Their mean scores for five multiple choice questions (MCQs) on warfarin pharmacokinetic and pharmacodynamic variability increased significantly from 45% (pre-workshop) to 81% (post-workshop), p < 0.05. A focus group interview also provided support that students learned by generating and testing their hypotheses via CoaguSim during the workshop. DISCUSSION AND SUMMARY The new workshop improved pharmacy students' understanding of the dose-response relationship of warfarin. Further development of the simulation to include other drugs is underway.
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Affiliation(s)
- Hesham Al-Sallami
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand.
| | - Swee-Kin Loke
- Otago Polytechnic, Forth Street, Private Bag 1910, Dunedin, New Zealand.
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Tarantino G, Capone D, Contaldi P, Gianno A, Teresa M, Tufano A. Phenotyping of CYP 4501A2 Activity by Total Overnight Salivary Caffeine Assessment (TOSCA) in Patients on Warfarin Treatment: A Cross-Sectional Study. Clin Appl Thromb Hemost 2018; 24:928-935. [PMID: 28992765 PMCID: PMC6714717 DOI: 10.1177/1076029617733040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Warfarin is an oral anticoagulant, commonly used for primary and secondary prevention of venous and arterial thromboembolic events. The drug is characterized by narrow therapeutic index, widespread individual variability in clinical response, and high rates of adverse events, particularly bleeding complications. For these reasons, a close monitoring of the dosage, using the frequent assessment of coagulation status by means of International Normalized Ratio value, is mandatory. Warfarin is metabolized by hepatic cytochrome P-450. High CYP 450 activity may lead to low drug concentration and requires high warfarin doses to reach efficacy; conversely, low CYP 450 activity is responsible for high drug concentration and needs for low doses to avoid potential toxicity risks. The major isoforms of CYP involved in the metabolism of warfarin sodium are CYP1A2 (for the R-warfarin) and CYP2C9 (for the S-warfarin). The probes for testing CYP1A2 are phenacetin and caffeine while for CYP2C9 tolbutamide. Although S-warfarin has major activity, it was decided to exclude its phenotyping for ethical issues, being mandatory to use a drug (tolbutamide). Instead, it was chosen to test the 1A2 isoform, as the activity of the latter isoform could be investigated by using caffeine contained in the caffeinated beverages. Specifically, a single-point concentration of salivary caffeine (total overnight salivary caffeine assessment [TOSCA]) after an overnight period of the caffeinated beverages abstinence was utilized. In the present study, 75 nonsmoker patients regularly receiving warfarin sodium were enrolled. The results have showed a significant association of the warfarin dose with TOSCA values (coefficient = -0.15, standard error = 0.04, 95% confidence interval = -0.24 to -0.06, t = -3.23, P = .002). In conclusion, the phenotyping of CYP1A2 by TOSCA could be useful, if further proven, to help manage patients on warfarin in order to lessen severe adverse events.
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Affiliation(s)
- Giovanni Tarantino
- Department of Clinical Medicine and Surgery, “Federico II” University, Naples, Italy
| | - Domenico Capone
- Integrated Care Department of Clinical Neurosciences, Anesthesiology and Drug-Use, Section of Clinical Pharmacology, “Federico II” University, Naples, Italy
| | - Paola Contaldi
- Department of Clinical Medicine and Surgery, “Federico II” University, Naples, Italy
| | - Adriana Gianno
- Department of Clinical Medicine and Surgery, “Federico II” University, Naples, Italy
| | - Mosca Teresa
- Integrated Care Department of Clinical Neurosciences, Anesthesiology and Drug-Use, Section of Clinical Pharmacology, “Federico II” University, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, “Federico II” University, Naples, Italy
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Tavares LC, Duarte NE, Marcatto LR, Soares RAG, Krieger JE, Pereira AC, Santos PCJL. Impact of incorporating ABCB1 and CYP4F2 polymorphisms in a pharmacogenetics-guided warfarin dosing algorithm for the Brazilian population. Eur J Clin Pharmacol 2018; 74:1555-1566. [PMID: 30051215 DOI: 10.1007/s00228-018-2528-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Interpatient variation of warfarin dose requirements may be explained by genetic variations and general and clinical factors. In this scenario, diverse population-calibrated dosing algorithms, which incorporate the main warfarin dosing influencers, have been widely proposed for predicting supposed warfarin maintenance dose, in order to prevent and reduce adverse events. The aim of the present study was to evaluate the impact of the inclusion of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms as additional covariates in a previously developed pharmacogenetic-based warfarin dosing algorithm calibrated for the Brazilian population. METHODS Two independent cohorts of patients treated with warfarin (n = 832 and n = 133) were included for derivation and replication of the algorithm, respectively. Genotyping of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms was performed by polymerase chain reaction followed by melting curve analysis and TaqMan® assay, respectively. A multiple linear regression was performed for the warfarin stable doses as a dependent variable, considering clinical, general, and genetic data as covariates. RESULTS The inclusion of ABCB1 and CYP4F2 polymorphisms was able to improve the algorithm's coefficient of determination (R2) by 2.6%. In addition, the partial determination coefficients of these variants revealed that they explained 3.6% of the warfarin dose variability. We also observed a marginal improvement of the linear correlation between observed and predicted doses (from 59.7 to 61.4%). CONCLUSION Although our study indicates that the contribution of the combined ABCB1 and CYP4F2 genotypes in explaining the overall variability in warfarin dose is not very large, we demonstrated that these pharmacogenomic data are statistically significant. However, the clinical relevance and cost-effective impact of incorporating additional variants in warfarin dosing algorithms should be carefully evaluated.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Nubia E Duarte
- Department of Mathematic and Statistics, Universidad Nacional de Colombia, Manizales, Caldas, Colombia
| | - Leiliane R Marcatto
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Renata A G Soares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Jose E Krieger
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Paulo Caleb Junior Lima Santos
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil.
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo UNIFESP, São Paulo, SP, Brazil.
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Takeda K, Ikenaka Y, Tanaka KD, Nakayama SMM, Tanikawa T, Mizukawa H, Ishizuka M. Investigation of hepatic warfarin metabolism activity in rodenticide-resistant black rats (Rattus rattus) in Tokyo by in situ liver perfusion. Pestic Biochem Physiol 2018; 148:42-49. [PMID: 29891376 DOI: 10.1016/j.pestbp.2018.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 02/26/2018] [Accepted: 03/25/2018] [Indexed: 06/08/2023]
Abstract
Anti-blood coagulation rodenticides, such as warfarin, have been used all over the world. They inhibit vitamin K epoxide reductase (VKOR), which is necessary for producing several blood clotting factors. This inhibition by rodenticides results in lethal hemorrhage in rodents. However, heavy usage of these agents has led to the appearance of rodenticide-resistant rats. There are two major mechanisms underlying this resistance, i.e., mutation of the target enzyme of warfarin, VKOR, and enhanced metabolism of warfarin. However, there have been few studies regarding the hepatic metabolism of warfarin, which should be related to resistance. To investigate warfarin metabolism in resistant rats, in situ liver perfusion of warfarin was performed with resistant black rats (Rattus rattus) from Tokyo, Japan. Liver perfusion is an in situ methodology that can reveal hepatic function specifically with natural composition of the liver. The results indicated enhanced hepatic warfarin hydroxylation activity compared with sensitive black rats. On the other hand, in an in vitro microsomal warfarin metabolism assay to investigate kinetic parameters of cytochrome P450, which plays a major role in warfarin hydroxylation, the Vmax of resistant rats was slightly but significantly higher compared to the results obtained in the in situ study. These results indicated that another factor like electron donators may also contribute to the enhanced metabolism in addition to high expression of cytochrome P450.
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Affiliation(s)
- Kazuki Takeda
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan
| | - Yoshinori Ikenaka
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan; Water Research Group, Unit for Environmental Sciences and Management, North-West University, Potchefstroom, South Africa
| | - Kazuyuki D Tanaka
- Technical Research Laboratory, IKARI SHODOKU CO. LTD., 1-12-3 Akanehama, Narashino, Chiba 275-0024, Japan
| | - Shouta M M Nakayama
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan
| | - Tsutomu Tanikawa
- Technical Research Laboratory, IKARI SHODOKU CO. LTD., 1-12-3 Akanehama, Narashino, Chiba 275-0024, Japan
| | - Hazuki Mizukawa
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan
| | - Mayumi Ishizuka
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan.
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Pastori D, Pignatelli P, Cribari F, Carnevale R, Saliola M, Violi F, Lip GY. Time to therapeutic range (TtTR), anticoagulation control, and cardiovascular events in vitamin K antagonists-naive patients with atrial fibrillation. Am Heart J 2018; 200:32-36. [PMID: 29898846 DOI: 10.1016/j.ahj.2018.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vitamin K antagonists (VKAs) reduce cardiovascular events (CVEs) in atrial fibrillation (AF) when a time in therapeutic range (TiTR) >70% is achieved. Factors affecting the time to achieve the TR (TtTR) are unknown. METHODS Prospective observational study including 1,406 nonvalvular AF patients starting VKAs followed for a mean of 31.3months (3,690 patient/year); TiTR, TtTR, and SAMe-TT2R2 score were calculated, and CVEs were recorded. RESULTS Median TtTR was 8.0days (interquartile range 5.0-18.0). Patients with high TtTR (ie, >75th percentile) were more likely to be in AF than in sinus rhythm at entry (odds ratio [OR]: 1.423, P=.011). Median TiTR was 60.0%; low TiTR (below median) was associated with SAMe-TT2R2 score (OR: 1.175, P=.001), high TtTR (>75th percentile, OR: 1.357, P=.017), and number of international normalized ratio checks (OR: 0.998, P=.049). We recorded 113 CVEs (3.1%/y), with a higher rate seen in patients with TtTR >75th percentile compared to those below (log-rank test, P=.006). A multivariable Cox regression analysis showed that SAMe-TT2R2 score (hazard ratio [HR]: 1.331, P<.001), TtTR >75th percentile (HR: 1.505, P=.047), TiTR <70% (HR: 1.931, P=.004), number of international normalized ratio checks (HR: 0.988, P<.001), digoxin (HR: 1.855, P=.008), and proton-pump inhibitors (HR: 0.452, P<.001) were independently associated with CVEs. CONCLUSIONS High TtTR is associated with poorer long-term quality of VKAs therapy. Patients with TtTR >18days or with high SAMe-TT2R2 score should be considered for treatment with non-vitamin K oral anticoagulants.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy; Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Cribari
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy; Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Mirella Saliola
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Gregory Yh Lip
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Hausner H, Derving Karsbøl J, Holst AG, Jacobsen JB, Wagner FD, Golor G, Anderson TW. Effect of Semaglutide on the Pharmacokinetics of Metformin, Warfarin, Atorvastatin and Digoxin in Healthy Subjects. Clin Pharmacokinet 2018; 56:1391-1401. [PMID: 28349387 PMCID: PMC5648738 DOI: 10.1007/s40262-017-0532-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Semaglutide is a glucagon-like peptide-1 analogue in development for the once-weekly treatment of type 2 diabetes mellitus. Its effect on the rate and extent of absorption of concomitant oral medications (metformin, warfarin, atorvastatin and digoxin) was evaluated in healthy subjects. METHODS Subjects received metformin (500 mg twice daily for 3.5 days), warfarin (25 mg, single dose), atorvastatin (40 mg, single dose) or digoxin (0.5 mg, single dose) before and with subcutaneous semaglutide treatment at steady state (1.0 mg). Lack of drug-drug interaction was concluded if the 90% confidence intervals for the area under the plasma concentration-time curve ratio before and with semaglutide were within a pre-specified interval (0.80-1.25). RESULTS Overall, metformin, warfarin, atorvastatin and digoxin pharmacokinetics were not affected to a clinically relevant degree with semaglutide co-administration. Estimated area under the plasma concentration-time curve ratios for all concomitant medications before and with semaglutide treatment were within the pre-specified interval. In addition, semaglutide did not affect maximum plasma concentration of concomitant medications to a relevant degree. Furthermore, no clinically relevant change in international normalised ratio response to warfarin was observed with semaglutide co-administration. Most adverse events with semaglutide treatment were mild or moderate. Adverse events with semaglutide and co-administered medication were comparable to those reported during treatment with semaglutide alone, and were mostly gastrointestinal related. CONCLUSIONS No clinically significant pharmacokinetic or pharmacodynamic interactions were identified and no new safety issues observed with combined treatment with semaglutide. This suggests that no dose adjustments should be required when semaglutide is administered concomitantly with these medications.
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Abstract
To evaluate the utility of a preemptive warfarin dose reduction at the time of initiation of either sulfamethoxazole-trimethoprim or metronidazole, a retrospective chart review of patients who received an outpatient prescription for warfarin and either sulfamethoxazole-trimethoprim and/or metronidazole from July 1, 2011 to July 1, 2015 was conducted. Clinical outcomes compared Veterans who had a warfarin dose reduction and those who did not within 120 h (5 days) of antibiotic initiation. The primary outcome compared the pre-and post-antibiotic International Normalized Ratio (INR) of patients in the intervention group (warfarin dose reduction) with those in the control group (no intervention). Secondary outcomes assessed incidence of thromboembolic and major bleeding events within 30 days of antibiotic completion. Fifty patients were assessed. Forty-nine patients had at least one follow-up appointment; 126 follow-up visits were evaluated. There was a statistically significant difference for the change in therapeutic INR at the first follow-up appointment (p = 0.029) for those patients in the control group. On average, the patients in the intervention group required fewer follow-up visits (p = 0.019). There were no statistically significant differences for the overall rate of therapeutic INR values between groups, as well as no instances of a thromboembolic or major bleeding events during the follow-up period. Clinically significant differences were observed for patients who received a preemptive warfarin dose reduction upon initiation of sulfamethoxazole-trimethoprim or metronidazole. Patients in the intervention group required fewer follow-up appointments and were more likely maintain a therapeutic INR within the 30 days following the antibiotic course. Results of this study will be presented the at Pharmacy and Therapeutics committee in an effort to seek approval for policy development to initiate a local preemptive warfarin dose adjustment as a standard of practice.
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Affiliation(s)
- Anna Powers
- Dayton Veterans Affairs Medical Center, 4100 West 3rd Street (119), Dayton, OH, 45428, USA.
| | - Erin B Loesch
- Dayton Veterans Affairs Medical Center, 4100 West 3rd Street (119), Dayton, OH, 45428, USA
| | - Anthony Weiland
- Dayton Veterans Affairs Medical Center, 4100 West 3rd Street (119), Dayton, OH, 45428, USA
| | | | - David Lucius
- Dayton Veterans Affairs Medical Center, 4100 West 3rd Street (119), Dayton, OH, 45428, USA
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Madhavan M, Hu TY, Gersh BJ, Roger VL, Killian J, Weston SA, Graff-Radford J, Asirvatham SJ, Chamberlain AM. Efficacy of Warfarin Anticoagulation and Incident Dementia in a Community-Based Cohort of Atrial Fibrillation. Mayo Clin Proc 2018; 93:145-154. [PMID: 29329798 PMCID: PMC5814135 DOI: 10.1016/j.mayocp.2017.09.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/21/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To study the association between time in therapeutic range (TTR) during warfarin therapy and risk of dementia in a population-based cohort of incident atrial fibrillation (AF). PATIENTS AND METHODS We conducted an observational population-based study of 2800 nondemented patients with incident AF from January 1, 2000, through December 31, 2010. The association of incident dementia with warfarin therapy and TTR was examined using Cox proportional hazards regression models. RESULTS Mean patient age was 71.2 years; 53% were men (n=1495), and warfarin was prescribed to 50.5% (n=1414) within 90 days of AF diagnosis. Incident dementia diagnosis occurred in 357 patients (12.8%) over a mean ± SD follow-up of 5.0±3.7 years. After adjusting for confounders, warfarin therapy was associated with a reduced incidence of dementia (hazard ratio [HR], 0.80; 95% CI, 0.64-0.99). However, only those in the 2 highest quartiles of TTR were associated with lower risk of dementia. A 10% increase in TTR with a 10% reduction in time spent in the subtherapeutic (HR, 0.71; 95% CI, 0.64-0.79) and supratherapeutic (HR, 0.67; 95% CI, 0.57-0.79) ranges were associated with decreased risk of dementia. CONCLUSION In the community, warfarin therapy for AF is associated with a 20% reduction in risk of dementia. Increasing TTR on warfarin is associated with reduced risk of dementia. The risk of dementia was reduced with a reduction in time spent in subtherapeutic and supratherapeutic international normalized ratio range. Effective anticoagulation may prevent cognitive impairment in patients with AF.
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Affiliation(s)
- Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Tiffany Y Hu
- Department of Medicine, University of California, Los Angeles
| | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Veronique L Roger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Jill Killian
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Susan A Weston
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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You JHS, Chan FWH, Wong RSM, Cheng G. The potential clinical and economic outcomes of pharmacogenetics-oriented management of warfarin therapy – a decision analysis. Thromb Haemost 2017; 92:590-7. [PMID: 15351856 DOI: 10.1160/th04-03-0161] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryVariant cytochrome P450 (CYP) 2C9 genotypes are associated with low maintenance dose requirement of warfarin therapy and increased risk of major bleeding events. The objective of the present study was to evaluate the potential clinical and economic outcomes of using CYP2C9 genotype data to guide the management of anticoagulation therapy and to identify influential factors affecting the cost-effectiveness of this treatment scheme. A decision tree was designed to simulate, over 12 months, the clinical and economic outcomes of patients newly started on warfarin associated with two alternatives: (1) no genotyping (non-genotyped group) and (2) CYP2C9 genotyping prior to initiation of warfarin therapy (genotyped group). Nongenotyped group patients would receive standard care of an anticoagulation clinic (AC). In the genotyped group, patients with at least one variant CYP2C9 allele would receive intensified anticoagulation service. Most of the clinical probabilities were derived from literature. The direct medical costs were estimated from the Diagnosis-Related Group charges and from literature. The total number of events and the direct medical cost per 100 patient-years in the genotyped and non-genotyped groups were 9.58 and USD155,700, and, 10.48 and USD 150,500, respectively. The marginal cost per additional major bleeding averted in the genotyped group was USD 5,778. The model was sensitive to the variation of the cost and reduction of bleeding rate in the intensified anticoagulation service. In conclusion, the pharmacogenetics-oriented management of warfarin therapy is potentially more effective in preventing bleeding with a marginal cost. The cost-effectiveness of this treatment scheme depends on the relative cost and effectiveness of a pharmacogenetics-oriented intensified anticoagulation service comparing to the standard AC care.
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Affiliation(s)
- Joyce H S You
- Centre for Pharmacoeconomics Research, School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong Shatin, N.T., Hong Kong, China.
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Vecsler M, Loebstein R, Almog S, Kurnik D, Goldman B, Halkin H, Gak E. Combined genetic profiles of components and regulators of the vitamin K-dependent γ-carboxylation system affect individual sensitivity to warfarin. Thromb Haemost 2017; 95:205-11. [PMID: 16493479 DOI: 10.1160/th05-06-0446] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryWe examined the influence of combined genotypes on interindividual variability in warfarin dose-response. In 100 anticoagulated patients we quantified the effects of polymorphisms in: CYP2C9, VKORC1, calumenin (CALU), γ-glutamyl carboxylase (GGCX) and microsomal epoxide hydrolase (EPHX1) on warfarin dose requirements. The G1542C VKORC1 polymorphism was associated with decreased warfarin doses in the heteroand homozygous mutant patients (21% and 50% lower, respectively; p<0.0001). Warfarin daily dose was predominantly determined by VKORC1 and CYP2C9 genotypes (partial r2= 0.21; 0.20, respectively). Together with age and body weight, these two genotypes explained 63% of the dose variance. A single patient, homozygous for G11A CALU mutant allele, required an excep tionally high warfarin dose (20mg/day) and the prevalence of heterozygous 11A allele carriers in the upper 10th dose percentile was significantly higher (0.27 vs. 0.18, p<0.02). Combined genotype analysis revealed that CYP2C9 andVKORC1 wild type and CALU mutant patients required the highest warfarin doses (7. 8±1. 5mg/day; n=9) as compared to the CYP2C9 and VKORC1 mutant and CALU wild type genotypes (2. 8±0. 3mg/day; n=18; p<0.01). The odds ratio for doses <3mg/day was 5. 9 (1.9–18. 4) for this genotype. Compound genetic profiles comprising VKORC1, CALU and CYP2C9 improve categorization of individual warfarin dose requirements in more than 25% of patients at steady-state anticoagulation.
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Affiliation(s)
- Manuela Vecsler
- Molecular Genetics Unit, Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer 52621, Israel
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Choi S, Oh DS, Jerng UM. A systematic review of the pharmacokinetic and pharmacodynamic interactions of herbal medicine with warfarin. PLoS One 2017; 12:e0182794. [PMID: 28797065 PMCID: PMC5552262 DOI: 10.1371/journal.pone.0182794] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 07/25/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives The aim of this study was to systematically review data regarding pharmacokinetic (PK)-pharmacodynamic (PD) parameters from randomized controlled trials relating to interactions between herbal medicines and warfarin. Methods Three electronic databases were searched to identify relevant trials. Two reviewers independently performed the study selection and data extraction. The risk of bias and reporting quality were also assessed independently by two reviewers using the Cochrane risk of bias tool and the consolidated standards of reporting trials (CONSORT). Outcomes were measured for all reported PK-PD parameters and adverse events. Results Nine randomized controlled trials met our inclusion criteria. Most of the included studies were unclear regarding the risk of bias and had a low quality of methodology. Using CONSORT, the reporting percentages for the articles ranged from 36.5% to 61.5% and the mean percentage for all articles was 45.6%. St John’s wort and echinacea affected the PK parameters of warfarin. Ginseng, ginger, garlic, and cranberry had no significant effect on the PK parameters. American ginseng altered the PD parameters of warfarin. St John’s wort, ginseng, Korea red ginseng, ginkgo, ginger, garlic, aged garlic, and echincea did not significantly alter the PD parameters. Studies of ginkgo and cranberry showed conflicting results on the PK parameters and PD parameters, respectively. The incidence of adverse events in all trials was low and no major adverse events were reported. Conclusions It was difficult to determine whether ten herbal medicines had significant effects on the PK-PD parameters of warfarin. Low quality of evidence, different compounds within and different compositions of the herbs, and methodological limitations of the crossover study, which is a clinical study in which subjects receive a sequence of different interventions, made it difficult to form conclusions. Additional studies that remedy these vulnerabilities are necessary to verify these results.
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Affiliation(s)
- Songie Choi
- The K-herb Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Dal-Seok Oh
- The K-herb Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Ui Min Jerng
- Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
- * E-mail:
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Young G, Male C, van Ommen CH. Anticoagulation in children: Making the most of little patients and little evidence. Blood Cells Mol Dis 2017; 67:48-53. [PMID: 28552476 DOI: 10.1016/j.bcmd.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/25/2017] [Accepted: 05/03/2017] [Indexed: 01/19/2023]
Abstract
Thrombotic complications are increasing at a steady and significant rate in children resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the standard agents (heparin, low molecular weight heparin, and vitamin K antagonists) and alternative agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the standard and alternative anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. Clearly, the standard anticoagulants all have significant shortcomings including variable pharmacokinetics, issues with therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The alternative anticoagulants have properties which overcome these shortcomings and prospective clinical trial data are presented supporting the current and future use of these agents in place of the standard anticoagulants.
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Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine.
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - C Heleen van Ommen
- Department of Pediatric Hematology/Oncology, Erasmus MC Sophia's Children's Hospital, Rotterdam, Netherlands
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Di Lullo L, Ronco C, Cozzolino M, Russo D, Russo L, Di Iorio B, De Pascalis A, Barbera V, Galliani M, Vitaliano E, Campana C, Santoboni F, Bellasi A. Nonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation. Thromb Res 2017; 155:38-47. [PMID: 28482261 DOI: 10.1016/j.thromres.2017.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, in CKD patients AF is associated with an increased risk of thromboembolism and stroke. However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with moderate to advanced chronic kidney disease (creatinine clearance 15-49ml/min) and those on dialysis.
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Affiliation(s)
- L Di Lullo
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy.
| | - C Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
| | - M Cozzolino
- Department of Health Sciences, Renal Division, S. Paolo Hospital, Milano, Italy
| | - D Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - L Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - B Di Iorio
- Department of Nephrology and Dialysis, Landolfi Hospital, Solofra, Italy
| | - A De Pascalis
- Department of Nephrology and Dialysis, V. Fazzi Hospital, Lecce, Italy
| | - V Barbera
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - M Galliani
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - E Vitaliano
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - C Campana
- Cardiology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
| | - F Santoboni
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - A Bellasi
- Nephrology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
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Tanaka A, Furubayashi T, Yamasaki H, Takano K, Kawakami M, Kimura S, Inoue D, Katsumi H, Sakane T, Yamamoto A. The Enhancement of Nasal Drug Absorption From Powder Formulations by the Addition of Sodium Carboxymethyl Cellulose. IEEE Trans Nanobioscience 2017; 15:798-803. [PMID: 28060709 DOI: 10.1109/tnb.2016.2612682] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For nasal drug absorption, powder formulations can be expected to provide many advantages. The first aim of this study was to examine drug absorption following nasal administration of powder formulations in rats. Pharmaceutical excipients are typically added to most powder formulations. The second aim was to investigate the change in nasal drug absorption of powder formulations in the presence of sodium carboxymethyl cellulose (CMC-Na). Model drugs used were norfloxacin (NFX), warfarin (WF), and piroxicam (PXC). The absorption from bulk powders is different from that of solutions. The absorption of PXC and WF from powder formulations was enhanced compared to those of the other solutions, while that of NFX, which has a low solubility, was decreased, suggesting that the nasal absorption of many drugs, except poorly soluble drugs, is enhanced when they are administered as powder formulations. CMC-Na enhanced the absorption of NFX and PXC. The presence of CMC-Na slightly decreased the absorption of WF. In vitro transepithelial transport from the powder formulation was not affected by the presence of CMC-Na. Furthermore, the nasal retention of the powder formulation was significantly increased in the presence of CMC-Na. In conclusion, the nasal absorption of many drugs, except those that are poorly soluble, can be increased by administering them as a powder formulation and the nasal absorption of the formulation is enhanced further in the presence of CMC-Na.
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Wiley LK, Vanhouten JP, Samuels DC, Aldrich MC, Roden DM, Peterson JF, Denny JC. STRATEGIES FOR EQUITABLE PHARMACOGENOMIC-GUIDED WARFARIN DOSING AMONG EUROPEAN AND AFRICAN AMERICAN INDIVIDUALS IN A CLINICAL POPULATION. Pac Symp Biocomput 2017; 22:545-556. [PMID: 27897005 PMCID: PMC5389380 DOI: 10.1142/9789813207813_0050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The blood thinner warfarin has a narrow therapeutic range and high inter- and intra-patient variability in therapeutic doses. Several studies have shown that pharmacogenomic variants help predict stable warfarin dosing. However, retrospective and randomized controlled trials that employ dosing algorithms incorporating pharmacogenomic variants under perform in African Americans. This study sought to determine if: 1) including additional variants associated with warfarin dose in African Americans, 2) predicting within single ancestry groups rather than a combined population, or 3) using percentage African ancestry rather than observed race, would improve warfarin dosing algorithms in African Americans. Using BioVU, the Vanderbilt University Medical Center biobank linked to electronic medical records, we compared 25 modeling strategies to existing algorithms using a cohort of 2,181 warfarin users (1,928 whites, 253 blacks). We found that approaches incorporating additional variants increased model accuracy, but not in clinically significant ways. Race stratification increased model fidelity for African Americans, but the improvement was small and not likely to be clinically significant. Use of percent African ancestry improved model fit in the context of race misclassification.
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Affiliation(s)
- Laura K Wiley
- Div. of Biomedical Informatics and Personalized Med., University of Colorado, 13001 E. 17th Pl. MS F-563 Aurora, CO 80045, USA,
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Li H, Zhang C, Fan R, Sun H, Xie H, Luo J, Wang Y, Lv H, Tang T. The effects of Chuanxiong on the pharmacokinetics of warfarin in rats after biliary drainage. J Ethnopharmacol 2016; 193:117-124. [PMID: 27497635 DOI: 10.1016/j.jep.2016.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/13/2016] [Accepted: 08/03/2016] [Indexed: 06/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Chuanxiong Rhizoma (rhizomes of Ligusticum chuanxiong Hort), known as Chuanxiong in Chinese, has been used for treating cardiovascular diseases for centuries. Chuanxiong is a classical activating blood circulation herb in the treatment of thromboembolism heart diseases. Warfarin often combines with herbal prescriptions containing Chuanxiong in China. AIM OF THE STUDY The herb-drug interaction involving enterohepatic circulation process remains unclear. This study aimed to elucidate the effects of Chuanxiong Rhizoma on the pharmacokinetics of warfarin in rats after biliary drainage. MATERIALS AND METHODS Thirty-two rats were randomly divided into four groups: WN (healthy rats after the gastric-administration of 0.5mg/kg warfarin sodium), WO (a rat model of biliary drainage after the gastric-administration of 0.5mg/kg warfarin sodium), WCN (healthy rats after the gastric-administration of 0.5mg/kg warfarin sodium and 10g/kg Chuanxiong decoction), and WCO (a rat model of biliary drainage after the gastric-administration of 0.5mg/kg warfarin sodium and 10g/kg Chuanxiong decoction). The levels of warfarin and internal standard were quantified by LC-MS/MS. Comparisons between groups were performed according to the main pharmacokinetic parameters calculated by the DAS 2.1.1 software. RESULTS The established LC-MS/MS method was specific, precise and rapid. The pharmacokinetic parameters showed a significant difference between the WN and WO groups. There were significant differences in the area under the curve (AUC0-t), peak concentration (Cmax), total plasma clearance (CLz/F) and mean residence time (MRT0-t) between the WCO and WCN groups; the AUC0-t of warfarin in the WCN group was 2.42 times than that of the WN group (p<0.01); the WCO group displayed a decreased to 61.6% in the Cmax compared the WO group (p<0.01). CONCLUSION Biliary drainage significantly influenced the disposition of warfarin, and Chuanxiong significantly affected the warfarin disposition in rat plasma.
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Affiliation(s)
- Haigang Li
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University, Changsha 410008, PR China; Department of Pharmacy, Changsha Medical University, Changsha 410219, PR China
| | - Chunhu Zhang
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Rong Fan
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Hua Sun
- Anhui Provincial Centre for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, PR China
| | - Haitang Xie
- Anhui Provincial Centre for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, PR China
| | - Jiekun Luo
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University, Changsha 410008, PR China
| | - Yang Wang
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University, Changsha 410008, PR China.
| | - Huiying Lv
- Hunan Agricultural Product Processing Institute, Hunan Academy of Agricultural Sciences, Changsha 410125, PR China.
| | - Tao Tang
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University, Changsha 410008, PR China.
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Strömberg EA, Nyberg J, Hooker AC. The effect of Fisher information matrix approximation methods in population optimal design calculations. J Pharmacokinet Pharmacodyn 2016; 43:609-619. [PMID: 27804003 PMCID: PMC5110617 DOI: 10.1007/s10928-016-9499-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/25/2016] [Indexed: 01/04/2023]
Abstract
With the increasing popularity of optimal design in drug development it is important to understand how the approximations and implementations of the Fisher information matrix (FIM) affect the resulting optimal designs. The aim of this work was to investigate the impact on design performance when using two common approximations to the population model and the full or block-diagonal FIM implementations for optimization of sampling points. Sampling schedules for two example experiments based on population models were optimized using the FO and FOCE approximations and the full and block-diagonal FIM implementations. The number of support points was compared between the designs for each example experiment. The performance of these designs based on simulation/estimations was investigated by computing bias of the parameters as well as through the use of an empirical D-criterion confidence interval. Simulations were performed when the design was computed with the true parameter values as well as with misspecified parameter values. The FOCE approximation and the Full FIM implementation yielded designs with more support points and less clustering of sample points than designs optimized with the FO approximation and the block-diagonal implementation. The D-criterion confidence intervals showed no performance differences between the full and block diagonal FIM optimal designs when assuming true parameter values. However, the FO approximated block-reduced FIM designs had higher bias than the other designs. When assuming parameter misspecification in the design evaluation, the FO Full FIM optimal design was superior to the FO block-diagonal FIM design in both of the examples.
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Affiliation(s)
- Eric A Strömberg
- Pharmacometrics Research Group, Department of Pharmaceutical Biosciences, Uppsala University, Box 471, 75124, Uppsala, Sweden.
| | - Joakim Nyberg
- Pharmacometrics Research Group, Department of Pharmaceutical Biosciences, Uppsala University, Box 471, 75124, Uppsala, Sweden
| | - Andrew C Hooker
- Pharmacometrics Research Group, Department of Pharmaceutical Biosciences, Uppsala University, Box 471, 75124, Uppsala, Sweden
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Takeda K, Ikenaka Y, Tanikawa T, Tanaka KD, Nakayama SMM, Mizukawa H, Ishizuka M. Novel revelation of warfarin resistant mechanism in roof rats (Rattus rattus) using pharmacokinetic/pharmacodynamic analysis. Pestic Biochem Physiol 2016; 134:1-7. [PMID: 27914534 DOI: 10.1016/j.pestbp.2016.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 06/06/2023]
Abstract
Roof rats (Rattus rattus) live mainly in human habitats. Heavy use of rodenticides, such as warfarin, has led to the development of drug resistance, making pest control difficult. There have been many reports regarding mutations of vitamin K epoxide reductase (VKOR), the target enzyme of warfarin, in resistant rats. However, it has been suggested there are other mechanisms of warfarin resistance. To confirm these possibilities, closed colonies of warfarin-susceptible roof rats (S) and resistant rats from Tokyo (R) were established, and the pharmacokinetics/pharmacodynamics of warfarin in rats from both colonies was investigated. R rats had low levels of warfarin in serum and high clearance activity. These rats can rapidly metabolize warfarin by hydroxylation. The levels of accumulation in the organs were lower than those of S rats. R rats administered warfarin showed high expression levels of CYP2B, 2C, and 3A, which play roles in warfarin hydroxylation, and may explain the high clearance ability of R rats. The mechanism of warfarin resistance in roof rats from Tokyo involved not only mutation of VKOR but also high clearance ability due to high levels of CYP2B, 2C and 3A expression possibly induced by warfarin.
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Affiliation(s)
- Kazuki Takeda
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan
| | - Yoshinori Ikenaka
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan; Water Research Group, Unit for Environmental Sciences and Management, North-West University, Potchefstroom, South Africa
| | - Tsutomu Tanikawa
- Technical Research Laboratory, Ikari Corporation, Chiba 260-0844, Japan
| | - Kazuyuki D Tanaka
- Technical Research Laboratory, Ikari Corporation, Chiba 260-0844, Japan
| | - Shouta M M Nakayama
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan
| | - Hazuki Mizukawa
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan
| | - Mayumi Ishizuka
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Kita-18 Nishi-9, Kita-ku, Sapporo 060-0818, Japan.
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