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On September 15, 2008, Acting Surgeon General Steven Galson, MD, MPH noted that blood clots contribute to the death of at least 100,000 Americans each year. Because many of these deaths occur suddenly where treatment is impossible, the best treatment is prevention. In this grant, researchers in Missouri and Utah develop strategies to improve the safety and effectiveness of clot prevention by customizing blood thinners to each person's genetic and clinical profile. They hypothesize that the use of genetics to guide warfarin therapy will reduce the risk of venous thromboembolism (VTE) postoperatively. They further hypothesize that using a target international normalized ratio (INR) of < 2.0 is non-inferior to using a target INR of 2.5 in clot prevention.
The overall objective of the Genetics-InFormatics Trial (GIFT) of Warfarin to Prevent DVT is to elucidate novel strategies to improve the safety and effectiveness of warfarin therapy. With this study we directly respond to Health and Human Services (HHS) priorities to advance the field of personalized medicine and to prevent venous thromboembolic disease. One year ago, the Honorable Mike Leavitt, Secretary of HHS, announced the Personalized Health Care Initiative and wrote that a key goal was, "… to use our personal genetic information to tailor treatments more effectively to each patient."(Leavitt, 2007) On September 15, 2008, the Acting Surgeon General (Dr. Steven K. Galson, MD, MPH) issued a Call to Action to reduce the number of cases of deep vein thrombosis and pulmonary embolism in the United States.(Galson, 2008) To facilitate the dosing strategies for the trial proposed herein and for the public at large, we have made publically available a non-profit, decision-support web application, www.WarfarinDosing.org.
Aim 1: To determine how pharmacogenetic-based warfarin therapy affects the safety and effectiveness of warfarin therapy. The intensity of anticoagulant therapy is measured by the International Normalized Ratio (INR). During initiation, the INR often falls outside the therapeutic range. INRs that are too low predispose patients to thromboembolism (Kearon, 2003) while supratherapeutic INR values increase risk of bleeding. (Hylek, 1994; Hylek, 2007) In August 2007, the FDA approved the label change of warfarin/Coumadin™ to recommend considering lower initial doses in patients known to have certain polymorphisms in genes affecting warfarin metabolism and sensitivity.(Wood, 2007) However, whether this strategy improves the safety and effectiveness of warfarin therapy in general is unknown. In particular, how this strategy affects subgroups with and without the genetic variants of interest is also unknown. To test the resulting joint hypothesis while preserving an Aim-wide Type I error rate of < 0.05 we will partition our expected error rate as described in the methods section below.
Primary Joint hypothesis: Pharmacogenetic therapy decreases the composite risk of a non-fatal VTE, non-fatal major hemorrhage, death, or INR>4.0 in all patients, and in the subgroup of patients whose pharmacogenetic and clinical predicted therapeutic maintenance doses differ by >1.0 mg/day. Based on our meta-analysis of prior trials (Hillman, 2005; Anderson, 2007; Caraco, 2008; Huang, 2009) (Sections B.3 and B.7 of grant proposal) and our pilot studies (Section C of grant proposal), we anticipate >99% power to simultaneously detect a reduction in the composite outcome, as measured by a chi-square test in both populations.
Aim 2: To determine whether warfarin therapy with a target INR of 1.8 is non-inferior to therapy with a target INR of 2.5 at preventing VTE or death in orthopedic patients. One randomized trial (PREVENT) found that a target INR value of 1.5-2.0 prevented 64% of VTE recurrence.(Ridker, 2003) Although that trial excluded orthopedic patients, such an approach has been endorsed by the American Academy of Orthopedic Surgeons (AAOS) and by many academic orthopedists (Table C.4). On page 15 of the latest AAOS guidelines (American Academy of Orthopaedic Surgeons, 2007) they offer the following recommendation for VTE prophylaxis around the time of joint replacement: "Warfarin, with an INR goal of ≤2.0, starting either the night before or the night after surgery, for 2-6 weeks." However, the AAOS grade the overall evidence for VTE prophylaxis in this population as low (level III) because no randomized trials have answered key clinical questions in this area—what is the optimal target INR value and whether pharmacogenetic therapy can improve clinical outcomes. The AAOS guidelines conflict with the American College of Chest Physician (ACCP) guidelines, (Geerts, 2004) which recommend, as one of their (Grade 1A) options (page 338S), using an "…adjusted-dose vitamin K antagonist (INR target, 2.5; range 2.0 to 3.0)." Because lower target INR values may reduce the risk of hemorrhage and simplify warfarin management (Ridker, 2003) we propose to test the following:
Hypothesis 2: For prevention of non-fatal VTE or death, a target INR of 1.8 will be non-inferior to a higher target INR (2.5). Using a non-inferiority margin of 10% (corresponding to a 1% absolute change in symptomatic VTE rate), we will have 80% power to detect the non-inferiority of a target INR of 1.8 in 1600 patients.
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Factorial Assignment, Masking: Double Blind (Subject, Caregiver, Investigator), Primary Purpose: Prevention
Pharmacogenetic Warfarin Initiation, Clinical Warfarin Initiation (non-pharmacogenetic)
Washington University in St. Louis, School of Medicine
Not yet recruiting
Washington University School of Medicine
Published on BioPortfolio: 2014-08-27T03:18:14-0400
Warfarin (also called Coumadin®) is an anticoagulant drug (blood thinner) given to patients to help prevent blood clots from forming or to help prevent the growth of an existing blood clo...
Warfarin is the most commonly used oral anticoagulant medicine (blood thinner). Although this medicine works well, it is difficult to know how much medicine a patient needs. Many things af...
Several human genes affect how medications are metabolized by the body. It is believed that knowledge of variations of these genes can help health care providers better manage an anticoagu...
Background: Time in therapeutic range (TTR) is a measurement of quality of warfarin therapy and lower TTR values (
We propose to develop a personalized pharmacogenetic approach including the major genetic markers of warfarin (coumadin) dosing and patients' age and weight. The known genetic determinants...
Venous thromboembolism chemoprophylaxis with warfarin is common after total joint arthroplasty. Early response to warfarin initiation has been theorized to engender a transient increase in the risk of...
Warfarin is a cornerstone for the prevention of thromboembolism in atrial fibrillation (AF), and several efforts have been taken to increase its usage and safety, including risk stratification schemes...
To evaluate the cost-utility of the pharmacogenetic-guided dosing of warfarin (PGx), when compared to the current dosing strategy.
To examine the knowledge, attitudes, and interest of an inner city population toward pharmacogenetic testing, with the primary objective of identifying facilitators and barriers toward pharmacogenetic...
Fetuses exposed to warfarin during pregnancy are at an increased risk of developing an embryopathy known as fetal warfarin syndrome or warfarin embryopathy. The most consistent anomalies are nasal hyp...
An anticoagulant that acts by inhibiting the synthesis of vitamin K-dependent coagulation factors. Warfarin is indicated for the prophylaxis and/or treatment of venous thrombosis and its extension, pulmonary embolism, and atrial fibrillation with embolization. It is also used as an adjunct in the prophylaxis of systemic embolism after myocardial infarction. Warfarin is also used as a rodenticide.
A eukaryotic initiation factor that binds to 40S ribosomal subunits. Although initially considered a "non-essential" factor for eukaryotic transcription initiation, eukaryotic initiation factor-1 is now thought to play an important role in localizing RIBOSOMES at the initiation codon of MRNA.
A component of eukaryotic initiation factor-4F that is involved in multiple protein interactions at the site of translation initiation. Thus it may serve a role in bringing together various initiation factors at the site of translation initiation.
A trimeric peptide initiation factor complex that associates with the 5' MRNA cap structure of RNA (RNA CAPS) and plays an essential role in MRNA TRANSLATION. It is composed of EUKARYOTIC INITIATION FACTOR-4A; EUKARYOTIC INITIATION FACTOR-4E; and EUKARYOTIC INITIATION FACTOR-4G.
A eukaryotic initiation factor that interacts with the 40S initiation complex and promotes the hydrolysis of the bound GTP. The hydrolysis of GTP causes the release of EUKARYOTIC INITIATION FACTOR-2 and EUKARYOTIC INITIATION FACTOR-3 from the 40S subunit and the subsequent joining of the 60S ribosomal subunit to the 40S complex to form the functional 80S initiation complex
Within medicine, nutrition (the study of food and the effect of its components on the body) has many different roles. Appropriate nutrition can help prevent certain diseases, or treat others. In critically ill patients, artificial feeding by tubes need t...