1
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Botnari M, Tchertanov L. Synergy of Mutation-Induced Effects in Human Vitamin K Epoxide Reductase: Perspectives and Challenges for Allo-Network Modulator Design. Int J Mol Sci 2024; 25:2043. [PMID: 38396721 PMCID: PMC10889538 DOI: 10.3390/ijms25042043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
The human Vitamin K Epoxide Reductase Complex (hVKORC1), a key enzyme transforming vitamin K into the form necessary for blood clotting, requires for its activation the reducing equivalents delivered by its redox partner through thiol-disulfide exchange reactions. The luminal loop (L-loop) is the principal mediator of hVKORC1 activation, and it is a region frequently harbouring numerous missense mutations. Four L-loop hVKORC1 mutants, suggested in vitro as either resistant (A41S, H68Y) or completely inactive (S52W, W59R), were studied in the oxidised state by numerical approaches (in silico). The DYNASOME and POCKETOME of each mutant were characterised and compared to the native protein, recently described as a modular protein composed of the structurally stable transmembrane domain (TMD) and the intrinsically disordered L-loop, exhibiting quasi-independent dynamics. The DYNASOME of mutants revealed that L-loop missense point mutations impact not only its folding and dynamics, but also those of the TMD, highlighting a strong mutation-specific interdependence between these domains. Another consequence of the mutation-induced effects manifests in the global changes (geometric, topological, and probabilistic) of the newly detected cryptic pockets and the alternation of the recognition properties of the L-loop with its redox protein. Based on our results, we postulate that (i) intra-protein allosteric regulation and (ii) the inherent allosteric regulation and cryptic pockets of each mutant depend on its DYNASOME; and (iii) the recognition of the redox protein by hVKORC1 (INTERACTOME) depend on their DYNASOME. This multifaceted description of proteins produces "omics" data sets, crucial for understanding the physiological processes of proteins and the pathologies caused by alteration of the protein properties at various "omics" levels. Additionally, such characterisation opens novel perspectives for the development of "allo-network drugs" essential for the treatment of blood disorders.
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Affiliation(s)
| | - Luba Tchertanov
- Centre Borelli, École Normale Supérieure (ENS) Paris-Saclay, Centre National de la Recherche Scientifique (CNRS), Université Paris-Saclay, 4 Avenue des Sciences, F-91190 Gif-sur-Yvette, France;
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2
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Dryden L, Song J, Valenzano TJ, Yang Z, Debnath M, Lin R, Topolovec-Vranic J, Mamdani M, Antoniou T. Evaluation of Machine Learning Approaches for Predicting Warfarin Discharge Dose in Cardiac Surgery Patients: Retrospective Algorithm Development and Validation Study. JMIR Cardio 2023; 7:e47262. [PMID: 38055310 PMCID: PMC10733832 DOI: 10.2196/47262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Warfarin dosing in cardiac surgery patients is complicated by a heightened sensitivity to the drug, predisposing patients to adverse events. Predictive algorithms are therefore needed to guide warfarin dosing in cardiac surgery patients. OBJECTIVE This study aimed to develop and validate an algorithm for predicting the warfarin dose needed to attain a therapeutic international normalized ratio (INR) at the time of discharge in cardiac surgery patients. METHODS We abstracted variables influencing warfarin dosage from the records of 1031 encounters initiating warfarin between April 1, 2011, and November 29, 2019, at St Michael's Hospital in Toronto, Ontario, Canada. We compared the performance of penalized linear regression, k-nearest neighbors, random forest regression, gradient boosting, multivariate adaptive regression splines, and an ensemble model combining the predictions of the 5 regression models. We developed and validated separate models for predicting the warfarin dose required for achieving a discharge INR of 2.0-3.0 in patients undergoing all forms of cardiac surgery except mechanical mitral valve replacement and a discharge INR of 2.5-3.5 in patients receiving a mechanical mitral valve replacement. For the former, we selected 80% of encounters (n=780) who had initiated warfarin during their hospital admission and had achieved a target INR of 2.0-3.0 at the time of discharge as the training cohort. Following 10-fold cross-validation, model accuracy was evaluated in a test cohort comprised solely of cardiac surgery patients. For patients requiring a target INR of 2.5-3.5 (n=165), we used leave-p-out cross-validation (p=3 observations) to estimate model performance. For each approach, we determined the mean absolute error (MAE) and the proportion of predictions within 20% of the true warfarin dose. We retrospectively evaluated the best-performing algorithm in clinical practice by comparing the proportion of cardiovascular surgery patients discharged with a therapeutic INR before (April 2011 and July 2019) and following (September 2021 and May 2, 2022) its implementation in routine care. RESULTS Random forest regression was the best-performing model for patients with a target INR of 2.0-3.0, an MAE of 1.13 mg, and 39.5% of predictions of falling within 20% of the actual therapeutic discharge dose. For patients with a target INR of 2.5-3.5, the ensemble model performed best, with an MAE of 1.11 mg and 43.6% of predictions being within 20% of the actual therapeutic discharge dose. The proportion of cardiovascular surgery patients discharged with a therapeutic INR before and following implementation of these algorithms in clinical practice was 47.5% (305/641) and 61.1% (11/18), respectively. CONCLUSIONS Machine learning algorithms based on routinely available clinical data can help guide initial warfarin dosing in cardiac surgery patients and optimize the postsurgical anticoagulation of these patients.
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Affiliation(s)
| | | | | | - Zhen Yang
- Unity Health Toronto, Toronto, ON, Canada
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3
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Kim JS, Lee S, Yee J, Park K, Jang EJ, Chang BC, Gwak HS. Novel Gene Polymorphisms for Stable Warfarin Dose in a Korean Population: Genome-Wide Association Study. Biomedicines 2023; 11:2308. [PMID: 37626805 PMCID: PMC10452379 DOI: 10.3390/biomedicines11082308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/03/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Warfarin has a narrow therapeutic window and high intra- and inter-individual variability. Considering that many published papers on genotype-guided dosing are derived from European populations, the aim of this study was to investigate novel genetic variants associated with the variability of stable warfarin dose in the Korean population with cardiac valve replacement, using the GWAS approach. This retrospective cohort study was performed from January 1982 to December 2020 at the Severance Cardiovascular Hospital of Yonsei University College of Medicine. GWAS was performed to identify associations between genotypes and the warfarin maintenance dose, by comparing the allele frequency of genetic variants between individuals. Then, the extent of genetic and non-genetic factors on the dose variability was determined by multivariable regression analysis. The study enrolled 214 participants, and the most robust signal cluster was detected on chromosome 16 around VKORC1. Followed by VKORC1, three novel variants (NKX2-6 rs310279, FRAS1 rs4386623, and FAM201A rs1890109) showed an association with stable warfarin dose requirement in univariate analysis. The algorithm was constructed by using multivariable analysis that includes genetic and non-genetic factors, and it could explain 58.5% of the variations in stable warfarin doses. In this variability, VKORC1 rs9934438 and FRAS1 rs4386623 accounted for 33.0% and 9.9%, respectively. This GWAS analysis identified the fact that three novel variants (NKX2-6 rs310279, FRAS1 rs4386623, and FAM201A rs1890109) were associated with stable warfarin doses. Additional research is necessary to validate the results and establish personalized treatment strategies for the Korean population.
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Affiliation(s)
- Jung Sun Kim
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea; (J.S.K.); (J.Y.); (E.J.J.)
| | - Sak Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Jeong Yee
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea; (J.S.K.); (J.Y.); (E.J.J.)
| | - Kyemyung Park
- Department of Biomedical Engineering, College of Information and Biotechnology, Ulsan National Institute of Science and Technology, Ulsan 44919, Republic of Korea;
| | - Eun Jeong Jang
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea; (J.S.K.); (J.Y.); (E.J.J.)
| | - Byung Chul Chang
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
- Department of Thoracic and Cardiovascular Surgery, Bundang CHA Medical Center, CHA University, Seongnam 13496, Republic of Korea
| | - Hye Sun Gwak
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea; (J.S.K.); (J.Y.); (E.J.J.)
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4
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Mausteller KG, Eisele CD, Julian K, Patel P, Bansal A, Jain R, Jain R. Anticoagulation and BMI: effect of high body weight on the safety and efficacy of direct oral anticoagulants. Future Cardiol 2022; 18:829-837. [PMID: 36052844 DOI: 10.2217/fca-2021-0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Obesity is an epidemic with rising prevalence, and obese patients are predisposed to comorbid conditions that increase risk for thromboembolic events. It is critical to identify safe and effective anticoagulation therapy for use in this population. Direct oral anticoagulants (DOACs) are a preferred option for anticoagulation in patients of normal weight due to many benefits and equivalent safety and efficacy to their vitamin K antagonist counterparts. However, the safety and efficacy of DOACs in obese patients is not well understood. This review describes recent studies on the pharmacokinetics, safety and efficacy, and clinical outcomes of the DOACs apixaban, rivaroxaban, edoxaban and dabigatran in obese patient populations. DOACs may be a beneficial alternative to vitamin K antagonist therapy in obese patient populations.
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Affiliation(s)
| | | | | | - Puja Patel
- Department of Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA 17033, USA
| | - Amit Bansal
- UHS Wilson Medical Center, Johnson City, NY 13790, USA
| | - Rahul Jain
- Division of Cardiology, University of Missouri Columbia Healthcare, Columbia, MO 65212, USA
| | - Rohit Jain
- Department of Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA 17033, USA
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5
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Todd KE, McGrady ME, Starbuck E, Previtera M, Luchtman-Jones L. A systematic review of adherence to anticoagulation regimens in pediatric patients. Pediatr Blood Cancer 2022; 69:e29698. [PMID: 35476901 DOI: 10.1002/pbc.29698] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 02/09/2022] [Accepted: 03/02/2022] [Indexed: 12/28/2022]
Abstract
Thromboembolic disease rates are increasing in pediatric patients. Anticoagulation is prescribed for treatment and prevention of thromboembolic disease. While nonadherence to anticoagulation regimens predicts poor health outcomes in adults, data in anticoagulated pediatric patients are limited. We systematically reviewed the rates, outcomes, and predictors of anticoagulation nonadherence in the pediatric population. Out of a total of 3581 unique articles identified for review, 17 studies met inclusion criteria. These studies primarily evaluated patients with cardiac disease treated with vitamin K antagonists. Overall nonadherence rates varied from 3% to 42%, based upon population, definition of adherence, and measurement strategy. Patient age, goal international normalized ratio (INR), and number of concurrent potentially interacting medications correlated with nonadherence. Data examining the relationship between nonadherence and health outcomes were included in only two studies. Limitations of current literature, as well as critical knowledge gaps that require future study, are discussed.
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Affiliation(s)
- Kevin E Todd
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meghan E McGrady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Patient Family and Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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6
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Sabry S, El Wakeel LM, Saleh A, Ahmed MA. Comparison of Warfarin Initiation at 3 mg Versus 5 mg for Anticoagulation of Patients with Mechanical Mitral Valve Replacement Surgery: A Prospective Randomized Trial. Clin Drug Investig 2022; 42:309-318. [PMID: 35274222 PMCID: PMC8989817 DOI: 10.1007/s40261-022-01137-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/01/2022]
Abstract
Background The increased warfarin sensitivity observed after mechanical mitral valve replacement (MVR) operations dictates clinical discretion in warfarin dose initiation. Evidence is still lacking with regard to anticoagulation management of MVR patients. Objective This study aimed to compare initiating warfarin at the recommended dosing regimen versus empirically lowered doses intended to account for the variation in warfarin sensitivity. Methods A prospective, single-blind, randomized, comparative study was conducted in postoperative MVR patients. Patients were randomly assigned to either the 5 mg group (n = 25) or the 3 mg group (n = 25) and were initiated on a 5 or 3 mg warfarin dose, respectively. Time to target international normalized ratio (INR), time in therapeutic range, occurrence of bleeding/thromboembolic events, and cost of bridging with enoxaparin were assessed for both groups. Results Target INR was achieved earlier in the 5 mg group than in the 3 mg group (p = 0.033), with a mean ± SD of 5.3 ± 2.0 and 6.6 ± 2.0, respectively (95% confidence interval of the mean difference 1.022–1.890). Bleeding events did not differ significantly between the two groups. The cost of enoxaparin consumption per patient was significantly higher in the 3 mg group versus the 5 mg group (p = 0.002). Conclusions The initiation of warfarin at a 5 mg dose in MVR patients was more efficacious than the 3 mg dose in terms of time to reach the target INR. Moreover, the cost of enoxaparin bridging was significantly reduced with a 5 mg warfarin initiation dose. Bleeding events were comparable. ClinicalTrials.gov ID NCT04235569, 22 January 2020.
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Affiliation(s)
- Sarah Sabry
- The Cardiovascular Hospital, Ain Shams University, Cairo, Egypt
| | - Lamia Mohamed El Wakeel
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, 8/4 Badr Street from Al Gazaer Street, New Maadi, Cairo, Egypt
| | - Ayman Saleh
- Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Marwa Adel Ahmed
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, 8/4 Badr Street from Al Gazaer Street, New Maadi, Cairo, Egypt.
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7
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Avarello I, Bianchi S, Toschi V, Zighetti ML, Faioni EM. Time in therapeutic range is lower in women than in men and is not explained by differences in age or comorbidity. Thromb Res 2021; 203:18-21. [PMID: 33901765 DOI: 10.1016/j.thromres.2021.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/18/2021] [Accepted: 04/06/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Time in therapeutic range (TTR) measures the stability of the international normalized ratio in patients on vitamin K antagonists (VKA). Low values are associated with poor outcomes. Women were shown to have lower TTR than men, but the causes are poorly defined. It was suggested that women on VKA are older and more morbid than men, and this could affect the stability of anticoagulation. We aimed to identify variables that affect TTR differently in women and men. MATERIALS AND METHODS This is a retrospective study in patients referred to a University hospital anticoagulant clinic. Age, sex, comorbidities, number of daily medications, indication and type of anticoagulant, weekly dosage and distribution, were derived from electronic records. Differences by sex and regression analysis to identify significant modulators of TTR were computed. RESULTS 1182 women and 1281 men on VKA were studied. Women were older than men (81.5 yrs. ± 11.2 vs 78.4 yrs. ± 12.2), and had lower TTR (65% ± 20.3 vs 69% ± 19.8). Comorbidity was similar between sexes and negatively affected TTR in both. Mechanical valves as an indication to anticoagulation and acenocoumarol as an anticoagulant as opposed to warfarin had a strong negative influence on TTR, while age increased TTR. Being a man rather than a woman afforded more than three TTR points. Number of medications and average anticoagulant dose were equal between sexes. DISCUSSION Women have a lower TTR than men, on average below the safety threshold. They were indeed older, but age positively influenced TTR. Since women and men were equally comorbid, neither age nor disease explains differences in TTR. None of the other variables included in the study could explain the gender gap in TTR. Since women are at increased risk of cardioembolic stroke in atrial fibrillation, an effort at defining other causes for the observed differences, closer monitoring and switching to direct anticoagulants whenever possible is warranted.
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Affiliation(s)
- Ilaria Avarello
- SIMT, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Susanna Bianchi
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Vincenzo Toschi
- SIMT, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | | | - Elena M Faioni
- SIMT, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy.
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8
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GERDAN V. Akılcı ilaç kullanımı: Varfarin. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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9
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Ahmed H, Saddouh EA, Abugrin ME, Ali AMM, Elgdhafi EO, Khaled A, Tarek A, Elhadi M. Association between Patients' Knowledge and Adherence to Anticoagulants, and Its Effect on Coagulation Control. Pharmacology 2020; 106:265-274. [PMID: 33202413 DOI: 10.1159/000511754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Warfarin requires strict monitoring by measuring prothrombin time (PT), international normalized ratio (INR), and time in therapeutic range (TTR). Several factors can lead to poor PT/INR control including vitamin K status, medication adherence, knowledge, and quality of life. The present study aims to assess patient adherence to warfarin treatment and its correlation with INR control. METHODS A cross-sectional study was conducted between October 2017 and January 2018 at Tripoli University Hospital. Data were collected by structured questionnaires which included; demographic and clinical characteristics, the Oral Anticoagulation Knowledge (OAK) test, and the Morisky Medication Adherence Scale (MMAS-8). RESULTS The final analysis included 88 out of 140 patients (73.33%). There were significant differences in age range, gender, marital status, and education level between the 2 groups (poor knowledge and adequate knowledge) (p < 0.05). There was a significant positive correlation between OAK test score and TTR. Overall, 76.2% of patients were adherent to warfarin (MMAS score ≥6) and 20.45% of patients were of high adherence (MMAS score of 8). The median score was 6 (IQR 6-7). A statistically significant, strong positive correlation between adherence to medication and TTR as an indicator of INR control was found (rs[86] = 0.472, p < 0.0001). CONCLUSION The study addressed and identified several areas for future improvement of patient outcomes. The implementation of new approaches to enhance patient knowledge and adherence is warranted, and measures to provide treatment for all patients that require it are needed, to improve outcomes and decrease adverse drug effects.
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Affiliation(s)
- Hazem Ahmed
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | | | | | | | | | - Ala Khaled
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Ahmed Tarek
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
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10
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Tyson RJ, Park CC, Powell JR, Patterson JH, Weiner D, Watkins PB, Gonzalez D. Precision Dosing Priority Criteria: Drug, Disease, and Patient Population Variables. Front Pharmacol 2020; 11:420. [PMID: 32390828 PMCID: PMC7188913 DOI: 10.3389/fphar.2020.00420] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/19/2020] [Indexed: 12/12/2022] Open
Abstract
The administered dose of a drug modulates whether patients will experience optimal effectiveness, toxicity including death, or no effect at all. Dosing is particularly important for diseases and/or drugs where the drug can decrease severe morbidity or prolong life. Likewise, dosing is important where the drug can cause death or severe morbidity. Since we believe there are many examples where more precise dosing could benefit patients, it is worthwhile to consider how to prioritize drug–disease targets. One key consideration is the quality of information available from which more precise dosing recommendations can be constructed. When a new more precise dosing scheme is created and differs significantly from the approved label, it is important to consider the level of proof necessary to either change the label and/or change clinical practice. The cost and effort needed to provide this proof should also be considered in prioritizing drug–disease precision dosing targets. Although precision dosing is being promoted and has great promise, it is underutilized in many drugs and disease states. Therefore, we believe it is important to consider how more precise dosing is going to be delivered to high priority patients in a timely manner. If better dosing schemes do not change clinical practice resulting in better patient outcomes, then what is the use? This review paper discusses variables to consider when prioritizing precision dosing candidates while highlighting key examples of precision dosing that have been successfully used to improve patient care.
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Affiliation(s)
- Rachel J Tyson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Christine C Park
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J Robert Powell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Weiner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Paul B Watkins
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Institute for Drug Safety Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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11
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Alshogran OY. Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition. Curr Drug Metab 2019; 20:633-645. [PMID: 31267868 DOI: 10.2174/1389200220666190701095807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD. METHODS Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized. RESULTS The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD. CONCLUSION Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.
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Affiliation(s)
- Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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12
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Smith J, Hanson J, Chowdhury R, Bungard TJ. Community-based management of epistaxis: Who bloody knows? Can Pharm J (Ott) 2019; 152:164-176. [PMID: 31156729 DOI: 10.1177/1715163519840380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jenna Smith
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
| | - Jennifer Hanson
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
| | - Raiyan Chowdhury
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
| | - Tammy J Bungard
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
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13
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Mohammadi K, Kargar M. Sensitivity to warfarin following cardiac surgery. Ther Adv Drug Saf 2018; 9:673-674. [PMID: 30546861 DOI: 10.1177/2042098618804488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Keyhan Mohammadi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Kargar
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, No. 92, Karimkhan-e-Zand Blvd. Haft-e-Tir Square, Tehran, Iran
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14
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Shendre A, Parmar GM, Dillon C, Beasley TM, Limdi NA. Influence of Age on Warfarin Dose, Anticoagulation Control, and Risk of Hemorrhage. Pharmacotherapy 2018; 38:588-596. [PMID: 29393514 DOI: 10.1002/phar.2089] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We assessed the influence of age on warfarin dose, percentage time in target range (PTTR), and risk of major hemorrhage. DESIGN Warfarin users recruited into a large prospective inception cohort study were categorized into three age groups: young (younger than 50 yrs), middle aged (50-70 yrs), and elderly (older than 70 yrs). The influence of age on warfarin dose and PTTR was assessed using regression analysis; risk of major hemorrhage was assessed using proportional hazards analysis. Models were adjusted for demographic, clinical, and genetic factors. SETTING Two outpatient anticoagulation clinics. PARTICIPANTS A total of 1498 anticoagulated patients. OUTCOMES Warfarin dose (mg/day), PTTR, major hemorrhage. RESULTS Of the 1498 patients, 22.8% were young, 44.1% were middle aged, and 33.1% were elderly. After accounting for clinical and genetic factors, compared with young warfarin users, warfarin dose requirements were 10.6% lower among the middle aged and an additional 10.6% lower for the elderly. Compared with young patients, middle-aged and elderly patients spent more time in target international normalized ratio (INR) range (p<0.0001), despite having fewer INR assessments (p<0.0001). Compared with young warfarin users, absolute risk of hemorrhage was marginally higher among the middle aged (p=0.08) and significantly higher among the elderly (p=0.016). Compared with young warfarin users, after adjustment, the relative risk of hemorrhage increased by 31% for each age category (p=0.026). CONCLUSIONS In a real-world setting, despite achieving better anticoagulation control, elderly patients had a higher risk of major hemorrhagic events. As the population ages and the candidacy for oral anticoagulation increases, strategies that mitigate the elevated risk of hemorrhage need to be identified.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
| | - Gaurav M Parmar
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy Mark Beasley
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Evaluation of CYP2C9- and VKORC1-based pharmacogenetic algorithm for warfarin dose in Gaza-Palestine. Future Sci OA 2018; 4:FSO276. [PMID: 29568565 PMCID: PMC5859345 DOI: 10.4155/fsoa-2017-0112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/22/2017] [Indexed: 12/13/2022] Open
Abstract
Aim To evaluate applicability of CYP2C9*2, *3 and VKORC1-1639G > A based algorithm to predict warfarin stable dose (WSD) in a group of Palestinian patients. Patients & methods Warfarin doses were retrospectively calculated for 101 Palestinian patients under warfarin therapy using three models. Performance of the three models was assessed in 47 patients found to take WSD. Results Frequency of CYP2C9*2, *3 and VKORC1-1639G > A alleles is 13.6, 0.0 and 46.5% respectively. The international warfarin pharmacogenetics consortium algorithm was more reliable (MAE = 8.9 ± 1.4; R2 = 0.350) than both the clinical algorithm (MAE = 10.4 ± 1.4; R2 = 0.128;) and the fixed-dose algorithm (MAE = 11.1 ± 1.7). Conclusion The international warfarin pharmacogenetics consortium algorithm can be reliably applied for predicting the WSD in Palestinian population.
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16
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Albrecht D, Turakhia MP, Ries D, Marbury T, Smith W, Dillon D, Milner PG, Midei MG. Pharmacokinetics of Tecarfarin and Warfarin in Patients with Severe Chronic Kidney Disease. Thromb Haemost 2017; 117:2026-2033. [PMID: 28933798 DOI: 10.1160/th16-10-0815] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Chronic kidney disease (CKD) complicates warfarin anticoagulation partially through its effect on CYP2C9 activity. Tecarfarin, a novel vitamin K antagonist, is not metabolized by CYP2C9. To evaluate the effect of CKD on their metabolism, we measured PK parameters of warfarin and tecarfarin in subjects with and without CKD. CKD subjects with estimated glomerular filtration rate < 30 mL/min not on dialysis (n = 13) were matched to healthy volunteers (HVs) (n = 10). Each subject was randomized to either warfarin 10 mg or tecarfarin 30 mg and was later crossed over to the other drug. PK parameters were measured following each drug. Mean plasma concentrations of (S)-warfarin and (R,S)-warfarin were higher (44 and 27%, respectively) in the subjects with CKD than in the healthy subjects. Both of these values fell outside of the 90% confidence interval of equivalence. For tecarfarin, the difference was less than 15% higher. Elimination half-life (t1/2) increased by 20% for (S)-warfarin and by 8% for (R,S)-warfarin and decreased by 8% for tecarfarin. The mean plasma concentration for tecarfarin's inactive metabolite ATI-5900 increased by approximately eightfold. CKD increased the effect of CYP2C9 genetic variation on (S)-warfarin and (R,S)-warfarin metabolism. Tecarfarin exposure was similar between the HVs and the CKD subjects regardless of CYP2C9 genotype. There were neither serious adverse events (SAEs) nor treatment-emergent adverse events (TEAEs) for any subject in the study. CKD inhibits metabolism of (S)-warfarin and (R,S)-warfarin, but not tecarfarin. The safety of repeated dosing of tecarfarin in CKD patients remains unknown. However, if the PK findings of this single-dose study are present with repeated dosing, tecarfarin may lead to dosing that is more predictable than warfarin in CKD patients who require anticoagulation therapy.
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Affiliation(s)
| | | | - Daniel Ries
- Prism Clinical Research, St. Paul, Minnesota, United States
| | - Thomas Marbury
- Orlando Clinical Research, Orlando, Florida, United States
| | - William Smith
- New Orleans Clinical Research, Knoxville Tennessee, United States
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17
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Time to achieving therapeutic international normalized ratio increases hospital length of stay after heart valve replacement surgery. Am Heart J 2017; 187:70-77. [PMID: 28454810 DOI: 10.1016/j.ahj.2017.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 02/08/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Achieving a therapeutic international normalized ratio (INR) before hospital discharge is an important inpatient goal for patients undergoing mechanical cardiac valve replacement (MCVR). The use of clinical algorithms has reduced the time to achieve therapeutic INR (TTI) with warfarin therapy. Whether TTI prolongs length of stay (LOS) is unknown. METHODS Patients who underwent MCVR over a consecutive 42-month period were included. Clinical data were obtained from the Society of Thoracic Surgeons Adult Cardiac Surgery database and electronic medical records. Therapeutic INR was defined as per standard guidelines. Warfarin dose was prescribed using an inpatient pharmacy-managed algorithm and computer-based dosing tool. International normalized ratio trajectory, procedural needs, and drug interactions were included in warfarin dose determination. RESULTS There were 708 patients who underwent MCVR, of which 159 were excluded for reasons that would preclude or interrupt warfarin use. Among the remainder of 549 patients, the average LOS was 6.4days and mean TTI was 3.5days. Landmark analysis showed that subjects in hospital on day 4 (n=542) who achieved therapeutic INR were more likely to be discharged by day 6 compared with those who did not achieve therapeutic INR (75% vs 59%, P<.001). Multivariable proportional hazards regression with TTI as a time-dependent effect showed a strong association with discharge (P=.0096, hazard ratio1.3) after adjustment for other significant clinical covariates. CONCLUSIONS Time to achieve therapeutic INR is an independent predictor of LOS in patients requiring anticoagulation with warfarin after MCVR surgery. Alternative dosing and anticoagulation strategies will need to be adopted to reduce LOS in these patients.
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The Active Metabolite of Warfarin (3'-Hydroxywarfarin) and Correlation with INR, Warfarin and Drug Weekly Dosage in Patients under Oral Anticoagulant Therapy: A Pharmacogenetics Study. PLoS One 2016; 11:e0162084. [PMID: 27606428 PMCID: PMC5015920 DOI: 10.1371/journal.pone.0162084] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 08/17/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives Warfarin oral anticoagulant therapy (OAT) requires regular and frequent drug adjustment monitored by INR. Interindividual variability, drug and diet interferences, and genetics (VKORC1 and CYP2C9) make the maintenance/reaching of stable INR a not so easy task. HPLC assessment of warfarin/enantiomers was suggested as a valid monitoring-tool along with INR, but definite results are still lacking. We evaluated possible correlations between INR, warfarin/3’-hydroxywarfarin, and drug weekly dosage aimed at searching novel alternatives to OAT monitoring. VKORC1/CYP2C9 pharmacogenetics investigation was performed to account for the known influence on warfarin homeostasis. Methods 133 OAT patients were recruited and assessed for warfarin/3’-hydroxywarfarin serum levels (HPLC), INR, and VKORC1 and CYP2C9 genotypes. A subgroup of 52 patients were monitored in detail (5 consecutive controls; c0-c4) till the target INR was reached. Correlation analyses were performed in both groups Results In the whole OAT group both warfarin and 3’-hydroxywarfarin correlate with INR at comparable degree (r2 = 0.0388 and 0.0362 respectively). Conversely, warfarin weekly dosage better correlates with warfarin than with 3’-hydroxywarfarin (r2 = 0.0975 and r2 = 0.0381 respectively), but considering together warfarin plus 3’-hydroxywarfarin the correlation strongly increased (r2 = 0.1114; p<0.0001). Interestingly, 3’-hydroxywarfarin reached a strong correlation at c4 respect to warfarin (r2 = 0.2157 and r2 = 0.0549; p = 0.0005 and p = 0.0944 respectively) seeming less affected by drug adjustments in the subgroup of 52 patients who started OAT. The multivariate analyses aimed at estimating the true contribution of 3’-hydroxywarfarin on INR value ascribed it the unique significant value (p = 0.0021) in spite of warfarin who lost association. The pharmacogenetics studies confirmed that patients carrying the VKORC1 variant-allele required lower warfarin maintenance dosage and that the combination of VKORC1 and CYP2C9 yielded a warfarin responsive index (WRI) inversely related to the number variant alleles Conclusion Our results overall suggest that 3’-hydroxywarfarin monitoring could be of great advantage in INR monitoring respect to classical warfarin assessment showing significant contribution also in multivariate analysis. Therefore, additional active metabolites should be recognized and investigated as novel useful indicators.
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Alshogran OY, Ocque AJ, Leblond FA, Pichette V, Nolin TD. Validation and Application of a Simple UHPLC-MS-MS Method for the Enantiospecific Determination of Warfarin in Human Urine. J Chromatogr Sci 2016; 54:554-60. [PMID: 26657732 PMCID: PMC4885390 DOI: 10.1093/chromsci/bmv186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 09/20/2015] [Indexed: 11/14/2022]
Abstract
A simple and rapid liquid chromatographic-tandem mass spectrometric method has been developed and validated for the enantiospecific determination of R- and S-warfarin in human urine. Warfarin enantiomers were extracted from urine using methyl tert-butyl ether. Chromatographic separation of warfarin enantiomers and the internal standard d5-warfarin was achieved using a Astec Chirobiotic V column with gradient mobile phase at a flow rate of 400 µL/min over 10 min. Detection was performed on a TSQ Quantum Ultra triple quadrupole mass spectrometer equipped with a heated electrospray ionization source. Analytes were detected in negative ionization mode using selected reaction monitoring. Calibration curves were linear with a correlation coefficient of ≥0.996 for both enantiomers over a concentration range of 5-500 ng/mL. The intra- and interday accuracy and precision for both analytes were within ±9.0%. Excellent extraction efficiency and negligible matrix effects were observed. The applicability of the method was demonstrated by successful measurement of warfarin enantiomers in urine of patients with kidney disease. The method is simple, accurate and reproducible and is currently being used to support warfarin pharmacokinetic studies.
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Affiliation(s)
- Osama Y Alshogran
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew J Ocque
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 208 Salk Pavillion, 335 Sutherland Drive, Pittsburgh, PA 15260, USA
| | - François A Leblond
- Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada
| | - Vincent Pichette
- Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada Département de Pharmacologie, Université de Montréal, Montréal, QC, Canada
| | - Thomas D Nolin
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 208 Salk Pavillion, 335 Sutherland Drive, Pittsburgh, PA 15260, USA
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20
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Daba FB, Tadesse F, Engidawork E. Drug-related problems and potential contributing factors in the management of deep vein thrombosis. BMC HEMATOLOGY 2016; 16:2. [PMID: 26855783 PMCID: PMC4743403 DOI: 10.1186/s12878-016-0043-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/22/2016] [Indexed: 02/02/2023]
Abstract
Background Patients receiving anticoagulant drugs must be carefully screened for drug-related problems, as such medications, including warfarin have narrow therapeutic ranges and a high potential for complications. Thus, this study was designed to assess drug-related problems in the management of patients with deep vein thrombosis at Tikur Anbessa Specialized Hospital. Methods A cross-sectional descriptive study involving retrospective chart review of adult patients with deep vein thrombosis was conducted from patients who visited the hospital from July 2012 to June 2013, using structured data collection format and this was complemented by key informant interview. Results The study included 91 patients with venous thromboembolism. Fifty three (58.2 %) were females. Mean age was 38.6 (±13.76) years and more than 2/3 were below the age of 44 years. About 54 % of them presented with concurrent medical conditions and most commonly with cancer. Adjustment of warfarin dose up or down was done in increments of 16 to 100 % for recent subtherapeutic International Normalized Ratios, 16 to 50 % for therapeutic and 11 to 66 % for overtherapeutic International Normalized Ratios, with the mean of 36.5 (±18.03) based on the cumulative weekly dose of warfarin. There was significant linear relationship between percentage of dose change and consequent International Normalized Ratio values (R2 = 0.419; p = 0.000). Accordingly, more than 51 % of them presented with nontherapeutic International Normalized Ratio ranges following dose adjustment. Conclusions The most prevalent anticoagulation drug-related problems were subtherapeutic doses, overtherapeutic doses and potential drug interactions. Institutional validated decision support tools for dosing decisions during maintenance anticoagulation therapy should be developed and used accordingly in order to prevent recurrent and hemorrhagic complications and to improve clinical outcomes.
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Affiliation(s)
- Fekede Bekele Daba
- Department of Pharmacy, College of Health Sciences, Jimma University, P.O. Box 378, Jimma, Ethiopia
| | - Fisihatsion Tadesse
- Department of Internal Medicine, Tikur Anbessa specialized hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia
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Comparison of dosing algorithms for acenocoumarol and phenprocoumon using clinical factors with the standard care in the Netherlands. Thromb Res 2015; 136:94-100. [DOI: 10.1016/j.thromres.2015.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/03/2015] [Accepted: 04/24/2015] [Indexed: 11/23/2022]
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Albadareen R, Thornton S, Heshmati A, Gerona R, Lowry J. Unusually Prolonged Presentation of Designer Drug Encephalopathy Responsive to Steroids. Pediatrics 2015; 136:e246-8. [PMID: 26055852 DOI: 10.1542/peds.2015-0073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 11/24/2022] Open
Abstract
The availability and use of novel psychoactive substances has risen dramatically over the last decade. The unpredictability of their toxicity constitutes a real challenge. We report a case of an adolescent who developed prolonged encephalopathy after ingesting "Hot Molly," which was found to contain the novel psychoactive substance, methylenedioxybenzylpiperazine when analyzed by high resolution mass spectrometry assay. This is the first case of human toxicity from methylenedioxybenzylpiperazine ingestion in the medical literature confirmed by body fluid analysis presenting with significant and prolonged encephalopathy. The prolonged course may be due to CYP2D6 inhibition from a combination of the methylenedioxyphenyl moiety and the patient's ultrarapid metabolizer pharmacokinetics. The response to high dose corticosteroids suggests a possible inflammatory effect that warrants further investigation.
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Affiliation(s)
| | - Stephen Thornton
- Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Arezou Heshmati
- Sections of Pediatric Neurology and Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Roy Gerona
- Department of Laboratory Medicine, University of California-San Francisco, San Francisco, California
| | - Jennifer Lowry
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri; and Clinical Toxicology, Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri
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Abstract
Objective We examined the potential effect of sex and age on warfarin dosing in ambulatory adult patients. Methods We conducted a retrospective chart review of patients attending an anticoagulation clinic. We included patients anticoagulated with warfarin for atrial fibrillation or venous thromboembolism who had a therapeutic international normalized ratio of 2–3 for 2 consecutive months. We excluded patients who had been on any drug that is known to have a major interaction with warfarin, smokers, and heavy alcohol consumers. Out of 340 screened medical records, 96 met the predetermined inclusion criteria. The primary outcome assessed was warfarin total weekly dose (TWD). Results There was a statistically significant difference in the TWD among the ages (P<0.01); older patients required lower doses. However there was no statistically significant difference in the TWD between sexes (P=0.281). Conclusion Age was found to have a significant effect on warfarin dosing. Even though women did require a lower TWD than men, this observation was not statistically significant.
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Affiliation(s)
- Ghada Khoury
- School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Marwan Sheikh-Taha
- Department of Pharmacy Practice, Lebanese American University, Byblos, Lebanon
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Guidoni CM, Obreli-Neto PR, Pereira LRL. Pharmacoepidemiologic study of warfarin prescription in a Brazilian tertiary hospital. J Thromb Thrombolysis 2013; 37:542-8. [DOI: 10.1007/s11239-013-1030-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Participation of Iatrogenically Coagulopathic Patients in Wilderness Activities. Wilderness Environ Med 2013; 24:257-66. [DOI: 10.1016/j.wem.2012.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 10/20/2012] [Accepted: 12/17/2012] [Indexed: 01/02/2023]
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26
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Gaikwad T, Ghosh K, Kulkarni B, Kulkarni V, Ross C, Shetty S. Influence of CYP2C9 and VKORC1 gene polymorphisms on warfarin dosage, over anticoagulation and other adverse outcomes in Indian population. Eur J Pharmacol 2013; 710:80-4. [DOI: 10.1016/j.ejphar.2013.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 03/28/2013] [Accepted: 04/09/2013] [Indexed: 11/29/2022]
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Basileo M, Micheluzzi C, Minozzi M, Lazzaroni L, Iorio A. Clinical validation of a new algorithm for computerized dosing of vitamin K antagonist therapy: a retrospective simulation study. Intern Emerg Med 2013; 8:55-63. [PMID: 21468696 DOI: 10.1007/s11739-011-0581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
Abstract
The number of patients on oral anticoagulant therapy has increased in recent years, and this trend is expected to continue. The increased workload for physicians has led to the development of computerized systems to make organizational workflow more efficient. These programs may include algorithms to propose a weekly dosage and timing for the following visit. Before introducing a new algorithm in clinical practice, its safety and efficacy must be validated. We undertook a retrospective simulation study to test a new algorithm for the TAOnet system. The main outcome was the percentage of concordant and discordant proposals between manual- and algorithm-based prescriptions. Pairs of computerized and physician prescriptions were assessed. They were categorized as 0.1-5, 5.1-10 and >10% if the dose was different, and assigned as "algorithm better" or "manual better" dependent upon the subsequent international normalized ratio value. In 61.0% of cases, the manual and computerized weekly dosage assignments were identical; in 15.3% of cases, the difference was between 0.1 and 5%; in 14.7 of cases, it was between 5.1 and 10%; and in 9.0% of cases, it was >10%. The algorithm did better in 43.9% of discordant pairs, generally due to less frequent under-dosing. In conclusion, the new algorithm proved to consistently overlap with the manual method. The algorithm is useful but must be tested in a multi-center, prospective, interventional study.
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Affiliation(s)
- Michela Basileo
- Department of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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Winter RL, Sedacca CD, Adams A, Orton EC. Aortic thrombosis in dogs: presentation, therapy, and outcome in 26 cases. J Vet Cardiol 2012; 14:333-42. [PMID: 22591640 DOI: 10.1016/j.jvc.2012.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 01/27/2012] [Accepted: 02/18/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The pathogenesis and presentation of aortic thrombosis (AT) in dogs is not well characterized and an effective antithrombotic therapy for AT in dogs has not been identified. Our goal is to report the clinical presentation and results of therapies in dogs with AT. ANIMALS Twenty-six client-owned dogs. METHODS Retrospective review of medical records of dogs diagnosed with AT between 2003 and 2010. RESULTS Twenty-six dogs had an apparent primary mural aortic thrombus. None had structural heart disease at diagnosis. Twenty dogs were ambulatory with varying degrees of pelvic limb dysfunction. Duration of ambulatory dysfunction was 7.8 weeks (range 1 day-52 weeks). A majority of dogs (58%) had no concurrent conditions at diagnosis. Fourteen dogs were treated with a standard warfarin protocol for a median period of 22.9 months (range 0.5-53 months). Ambulatory function improved in all dogs treated with warfarin. Time until clinical improvement was 13.9 days (range 2-49 days). Dogs treated with warfarin did not become non-ambulatory, die or undergo euthanasia related to AT, or have a known serious hemorrhagic event. CONCLUSIONS The pathogenesis of AT in dogs is distinct from that of aortic thromboembolism (ATE) in cats. Aortic thrombosis in dogs is more likely to involve local thrombosis in the distal aorta with embolization to the arteries of the pelvic limb resulting in chronic progressive ambulatory dysfunction. Chronic warfarin administration is well-tolerated and appears to be an effective short-term and long-term therapy for dogs with AT.
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Affiliation(s)
- Randolph L Winter
- Department of Clinical Sciences, Texas A&M University, College Station, TX, USA.
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