Abstract
Warfarin is a widely prescribed anticoagulant for thromboembolic disorders and exhibits wide inter-individual differences in its pharmacodynamic effects. Warfarin exerts its anticoagulant effect by inhibiting the enzymatic activity of vitamin K 2,3-epoxide reductase complex, subunit 1 (VKORC1) which regenerates reduced vitamin K as an essential cofactor for the post-translational γ-carboxylation of glutamic acid residues on coagulation factors II, VII, IX and X, and the anticoagulant proteins C, S and Z. Recent studies have shown polymorphisms in genes involved in the uptake of vitamin K (apolipoprotein E [ApoE]), reduction of vitamin K 2,3-epoxide (VKORC1), metabolism of warfarin (cytochrome P450 2C9 [CYP2C9]), and gamma carboxylation (γ-glutamyl carboxylase [GGCX]) to influence the pharmacokinetics and pharmacodynamics of warfarin in patients from different ethnic backgrounds, resulting in variable warfarin dose requirements. Understanding the causal relationship of these polygenic influences on warfarin dose requirements in patients of different ethnicity may be vital in reducing inter-patient variability and optimising anticoagulant therapy.
Similar content being viewed by others
References
Anand SS, Yusuf S. Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis. JAMA 1999 Dec; 282(21): 2058–67
Smith P, Arnesen H, Holme I. The effect of warfarin on mortality and reinfarction after myocardial infarction. N Engl J Med 1990 Jul 19; 323(3): 147–52
Hirsh J, Dalen JE, Anderson DR, et al. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest 1998 Nov; 114 (5 Suppl.): 445S–69S
Crowther MA, Ginsberg JB, Kearon C, et al. A randomized trial comparing 5mg and 10mg warfarin loading doses. Arch Intern Med 1999 Jan 11; 159(1): 46–8
Kovacs MJ, Rodger M, Anderson DR, et al. Comparison of 10mg and 5mg warfarin initiation nomograms together with low-molecular-weight heparin for outpatient treatment of acute venous thromboembolism: a randomized, double-blind, controlled trial. Ann Intern Med 2003 May 6; 138(9): 714–9
Fennerty A, Dolben J, Thomas P, et al. Flexible induction dose regimen for warfarin and prediction of maintenance dose. Br Med J (Clin Res Ed) 1984 Apr 28; 288(6426): 1268–70
Beyth RJ, Milligan PE, Gage BF. Risk factors for bleeding in patients taking coumarins. Curr Hematol Rep 2002 Sep; 1(1): 41–9
Wells PS, Holbrook AM, Crowther NR, et al. Interactions of warfarin with drugs and food. Ann Intern Med 1994 Nov 1; 121(9): 676–83
Voora D, Eby C, Linder MW, et al. Prospective dosing of warfarin based on cytochrome P-450 2C9 genotype. Thromb Haemost 2005 Apr; 93(4): 700–5
Breckenridge A, Orme M, Wesseling H, et al. Pharmacokinetics and pharmacodynamics of the enantiomers of warfarin in man. Clin Pharmacol Ther 1974 Apr; 15(4): 424–30
Takahashi H, Echizen H. Pharmacogenetics of warfarin elimination and its clinical implications. Clin Pharmacokinet 2001; 40(8): 587–603
O’Reilly RA. Studies on the optical enantiomorphs of warfarin in man. Clin Pharmacol Ther 1974 Aug; 16(2): 348–54
Shimada T, Yamazaki H, Mimura M, et al. Interindividual variations in human liver cytochrome P-450 enzymes involved in the oxidation of drugs, carcinogens and toxic chemicals: studies with liver microsomes of 30 Japanese and 30 Caucasians. J Pharmacol Exp Ther 1994; 270: 414–23
Inoue K, Yamazaki H, Imiya K, et al. Relationship between CYP2C9 and 2C19 genotypes and tolbutamide methyl hydroxylation and S-mephenytoin 4′-hydroxylation activities in livers of Japanese and Caucasian populations. Pharmacogenetics 1997 Apr; 7(2): 103–13
Rendic S, Di Carlo FJ. Human cytochrome P450 enzymes: a status report summarizing their reactions, substrates, inducers, and inhibitors. Drug Metab Rev 1997 Feb–May; 29(1–2): 413–580
Bajpai M, Roskos LK, Shen DD, et al. Roles of cytochrome P4502C9 and cytochrome P4502C19 in the stereoselective metabolism of phenytoin to its major metabolite. Drug Metab Dispos 1996 Dec; 24(12): 1401–3
Miners JO, Rees DL, Valente L, et al. Human hepatic cytochrome P450 2C9 catalyzes the rate-limiting pathway of torsemide metabolism. J Pharmacol Exp Ther 1995 Mar; 272(3): 1076–81
Miners JO, Birkett DJ. Use of tolbutamide as a substrate probe for human hepatic cytochrome P450 2C9. Methods Enzymol 1996; 272: 139–45
Kidd RS, Straughn AB, Meyer MC, et al. Pharmacokinetics of chlorpheniramine, phenytoin, glipizide and nifedipine in an individual homozygous for the CYP2C9*3 allele. Pharmacogenetics 1999 Feb; 9(1): 71–80
Stearns RA, Chakravarty PK, Chen R, et al. Biotransformation of losartan to its active carboxylic acid metabolite in human liver microsomes: role of cytochrome P4502C and 3A subfamily members. Drug Metab Dispos 1995 Feb; 23(2): 207–15
Bourrie M, Meunier V, Berger Y, et al. Role of cytochrome P-4502C9 in irbesartan oxidation by human liver microsomes. Drug Metab Dispos 1999 Feb; 27(2): 288–96
Goldstein JA, de Morais SM. Biochemistry and molecular biology of the human CYP2C subfamily. Pharmacogenetics 1994 Dec; 4(6): 285–99
Hamman MA, Thompson GA, Hall SD. Regioselective and stereoselective metabolism of ibuprofen by human cytochrome P450 2C. Biochem Pharmacol 1997 Jul 1; 54(1): 33–41
Meehan RR, Gosden JR, Rout D, et al. Human cytochrome P-450 PB-1: a multigene family involved in mephenytoin and steroid oxidations that maps to chromosome 10. Am J Hum Genet 1988 Jan; 42(1): 26–37
de Morais SM, Schweikl H, Blaisdell J, et al. Gene structure and upstream regulatory regions of human CYP2C9 and CYP2C18. Biochem Biophys Res Commun 1993 Jul 15; 194(1): 194–201
Shintani M, Ieiri I, Inoue K, et al. Genetic polymorphisms and functional characterization of the 5′-flanking region of the human CYP2C9 gene: in vitro and in vivo studies. Clin Pharmacol Ther 2001 Aug; 70(2): 175–82
Takahashi H, Ieiri I, Wilkinson GR, et al. 5’-Flanking region polymorphisms of CYP2C9 and their relationship to S-warfarin metabolism in white and Japanese patients. Blood 2004 Apr 15; 103(8): 3055–7
Veenstra DL, Blough DK, Higashi MK, et al. CYP2C9 haplotype structure in European American warfarin patients and association with clinical outcomes. Clin Pharmacol Ther 2005; 77(5): 353–64
King BP, Khan TI, Aithal GP, et al. Upstream and coding region CYP2C9 polymorphisms: correlation with warfarin dose and metabolism. Pharmacogenetics 2004 Dec; 14(12): 813–22
CYP2C9 allele nomenclature [online]. Available from URL: http://www.cypalleles.ki.se/cyp2c9.htm [Accessed 2006 October 3]
Gage BF, Eby C, Milligan PE, et al. Use of pharmacogenetics and clinical factors to predict the maintenance dose of warfarin. Thromb Haemost 2004 Jan; 91(1): 87–94
Margaglione M, Colaizzo D, D’Andrea G, et al. Genetic modulation of oral anticoagulation with warfarin. Thromb Haemost 2000 Nov; 84(5): 775–8
Taube J, Halsall D, Baglin T. Influence of cytochrome P-450 CYP2C9 polymorphisms on warfarin sensitivity and risk of over-anticoagulation in patients on long-term treatment. Blood 2000 Sep 1; 96(5): 1816–9
Scordo MG, Pengo V, Spina E, et al. Influence of CYP2C9 and CYP2C19 genetic polymorphisms on warfarin maintenance dose and metabolic clearance. Clin Pharmacol Ther 2002 Dec; 72(6): 702–10
Schalekamp T, van Geest-Daalderop JH, de Vries-Goldschmeding H, et al. Acenocoumarol stabilization is delayed in CYP2C93 carriers. Clin Pharmacol Ther 2004 May; 75(5): 394–402
Aynacioglu AS, Brockmoller J, Bauer S, et al. Frequency of cytochrome P450 CYP2C9 variants in a Turkish population and functional relevance for phenytoin. Br J Clin Pharmacol 1999 Sep; 48(3): 409–15
Scordo MG, Aklillu E, Yasar U, et al. Genetic polymorphism of cytochrome P450 2C9 in a Caucasian and a black African population. Br J Clin Pharmacol 2001 Oct; 52(4): 447–50
Peyvandi F, Spreafico M, Siboni SM, et al. CYP2C9 genotypes and dose requirements during the induction phase of oral anticoagulant therapy. Clin Pharmacol Ther 2004 Mar; 75(3): 198–203
Garcia-Martin E, Martinez C, Ladero JM, et al. High frequency of mutations related to impaired CYP2C9 metabolism in a Caucasian population. Eur J Clin Pharmacol 2001 Apr; 57(1): 47–9
Dickmann LJ, Rettie AE, Kneller MB, et al. Identification and functional characterization of a new CYP2C9 variant (CYP2C9*5) expressed among African Americans. Mol Pharmacol 2001 Aug; 60(2): 382–7
Yoon YR, Shon JH, Kim MK, et al. Frequency of cytochrome P450 2C9 mutant alleles in a Korean population. Br J Clin Pharmacol 2001 Mar; 51(3): 277–80
Takahashi H, Kashima T, Nomizo Y, et al. Metabolism of warfarin enantiomers in Japanese patients with heart disease having different CYP2C9 and CYP2C19 genotypes. Clin Pharmacol Ther 1998 May; 63(5): 519–28
Nasu K, Kubota T, Ishizaki T. Genetic analysis of CYP2C9 polymorphism in a Japanese population. Pharmacogenetics 1997 Oct; 7(5): 405–9
Bhasker CR, Miners JO, Coulter S, et al. Allelic and functional variability of cytochrome P4502C9. Pharmacogenetics 1997 Feb; 7(1): 51–8
Stubbins MJ, Harries LW, Smith G, et al. Genetic analysis of the human cytochrome P450 CYP2C9 locus. Pharmacogenetics 1996 Oct; 6(5): 429–39
Lee CR, Goldstein JA, Pieper JA. Cytochrome P450 2C9 polymorphisms: a comprehensive review of the in-vitro and human data. Pharmacogenetics 2002 Apr; 12(3): 251–63
Sullivan-Klose TH, Ghanayem BI, Bell DA, et al. The role of the CYP2C9-Leu359 allelic variant in the tolbutamide polymorphism. Pharmacogenetics 1996 Aug; 6(4): 341–9
Rettie AE, Wienkers LC, Gonzalez FJ, et al. Impaired (S)-warfarin metabolism catalysed by the R144C allelic variant of CYP2C9. Pharmacogenetics 1994 Feb; 4(1): 39–42
Kidd RS, Curry TB, Gallagher S, et al. Identification of a null allele of CYP2C9 in an African-American exhibiting toxicity to phenytoin. Pharmacogenetics 2001 Dec; 11(9): 803–8
Crespi CL, Miller VP. The R144C change in the CYP2C9*2 allele alters interaction of the cytochrome P450 with NADPH:cytochrome P450 oxidoreductase. Pharmacogenetics 1997 Jun; 7(3): 203–10
Takanashi K, Tainaka H, Kobayashi K, et al. CYP2C9 Ile359 and Leu359 variants: enzyme kinetic study with seven substrates. Pharmacogenetics 2000 Mar; 10(2): 95–104
Rettie AE, Haining RL, Bajpai M, et al. A common genetic basis for idiosyncratic toxicity of warfarin and phenytoin. Epilepsy Res 1999 Jul; 35(3): 253–5
Haining RL, Hunter AP, Veronese ME, et al. Allelic variants of human cytochrome P450 2C9: baculovirus-mediated expression, purification, structural characterization, substrate stereoselectivity, and prochiral selectivity of the wild-type and I359L mutant forms. Arch Biochem Biophys 1996 Sep 15; 333(2): 447–58
Takahashi H, Kashima T, Nomoto S, et al. Comparisons between in-vitro and in-vivo metabolism of (S)-warfarin: catalytic activities of cDNA-expressed CYP2C9, its Leu359 variant and their mixture versus unbound clearance in patients with the corresponding CYP2C9 genotypes. Pharmacogenetics 1998 Oct; 8(5): 365–73
Steward DJ, Haining RL, Henne KR, et al. Genetic association between sensitivity to warfarin and expression of CYP2C9*3. Pharmacogenetics 1997 Oct; 7(5): 361–7
Sherrill BC, Innerarity TL, Mahley RW. Rapid hepatic clearance of the canine lipoproteins containing only the E apoprotein by a high affinity receptor. Identity with the chylomicron remnant transport process. J Biol Chem 1980 Mar 10; 255(5): 1804–7
D’Andrea G, D’Ambrosio RL, Di Perna P, et al. A polymorphism in the VKORC1 gene is associated with an interindividual variability in the dose-anticoagulant effect of warfarin. Blood 2005 Jan 15; 105(2): 645–9
Yuan HY, Chen JJ, Lee MT, et al. A novel functional VKORC1 promoter polymorphism is associated with inter-individual and inter-ethnic differences in warfarin sensitivity. Hum Mol Genet 2005 Jul 1; 14(13): 1745–51
Wu SM, Stafford DW, Frazier LD, et al. Genomic sequence and transcription start site for the human gamma-glutamyl carboxylase. Blood 1997 Jun 1; 89(11): 4058–62
Suttie JW, Canfield LM, Shah DV. Microsomal vitamin K-dependent carboxylase. Methods Enzymol 1980; 67: 180–5
Corbo RM, Scacchi R. Apolipoprotein E (APOE) allele distribution in the world: is APOE*4 a ‘thrifty’ allele? Ann Hum Genet 1999 Jul; 63(Pt 4): 301–10
Weintraub MS, Eisenberg S, Breslow JL. Dietary fat clearance in normal subjects is regulated by genetic variation in apolipoprotein E. J Clin Invest 1987 Dec; 80(6): 1571–7
Aithal GP, Day CP, Kesteven PJ, et al. Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet 1999 Feb 27; 353(9154): 717–9
Halkin H, Lubetsky A. Warfarin dose requirement and CYP2C9 polymorphisms. Lancet 1999 Feb 27; 353(9154): 717–9
Furuya H, Fernandez-Salguero P, Gregory W, et al. Genetic polymorphism of CYP2C9 and its effect on warfarin maintenance dose requirement in patients undergoing anticoagulation therapy. Pharmacogenetics 1995 Dec; 5(6): 389–92
Cain D, Hutson SM, Wallin R. Warfarin resistance is associated with a protein component of the vitamin K 2,3-epoxide reductase enzyme complex in rat liver. Thromb Haemost 1998 Jul; 80(1): 128–33
Li T, Chang CY, Jin DY, et al. Identification of the gene for vitamin K epoxide reductase. Nature 2004 Feb 5; 427(6974): 541–4
Rost S, Fregin A, Ivaskevicius V, et al. Mutations in VKORC1 cause warfarin resistance and multiple coagulation factor deficiency type 2. Nature 2004 Feb 5; 427(6974): 537–41
Sconce EA, Khan TI, Wynne HA, et al. The impact of CYP2C9 and VKORC1 genetic polymorphism and patient characteristics upon warfarin dose requirements: proposal for a new dosing regimen. Blood 2005; 106(7): 2329–33
Wadelius M, Chen LY, Dowries K, et al. Common VKORC1 and GGCX polymorphisms associated with warfarin dose. Pharmacogenomics J 2005; 5(4): 262–70
Rieder MJ, Reiner AP, Gage BF, et al. Effect of VKORC1 haplotypes on transcriptional regulation and warfarin dose. N Engl J Med 2005 Jun 2; 352(22): 2285–93
Lee SC, Ng SS, Oldenburg J, et al. Interethnic variability of warfarin maintenance requirement is explained by VKORC1 genotype in an Asian population. Clin Pharmacol Ther 2006 Mar; 79(3): 197–205
Veenstra DL, You JH, Rieder MJ, et al. Association of vitamin K epoxide reductase complex 1 (VKORC1) variants with warfarin dose in a Hong Kong Chinese patient population. Pharmacogenet Genomics 2005 Oct; 15(10): 687–91
Kuo WL, Stafford DW, Cruces J, et al. Chromosomal localization of the gamma-glutamyl carboxylase gene at 2pl2. Genomics 1995 Feb 10; 25(3): 746–8
Manfioletti G, Brancolini C, Avanzi G, et al. The protein encoded by a growth arrest-specific gene (gas6) is a new member of the vitamin K-dependent proteins related to protein S, a negative coregulator in the blood coagulation cascade. Mol Cell Biol 1993 Aug; 13(8): 4976–85
Shikata E, Ieiri I, Ishiguro S, et al. Association of pharmacokinetic (CYP2C9) and pharmacodynamic (factors II, VII, IX, and X; proteins S and C; and gamma-glutamyl carboxylase) gene variants with warfarin sensitivity. Blood 2004 Apr 1; 103(7): 2630–5
Das HK, McPherson J, Brans GA, et al. Isolation, characterization, and mapping to chromosome 19 of the human apolipoprotein E gene. J Biol Chem 1985 May 25; 260(10): 6240–7
Rall Jr SC, Weisgraber KH, Mahley RW. Human apolipoprotein E: the complete amino acid sequence. J Biol Chem 1982 Apr 25; 257(8): 4171–8
Talmud PJ, Humphries SE. Gene: environment interaction in lipid metabolism and effect on coronary heart disease risk. Curr Opin Lipidol 2002 Apr; 13(2): 149–54
Mahley RW. Apolipoprotein E: cholesterol transport protein with expanding role in cell biology. Science 1988 Apr 29; 240(4852): 622–30
Zannis VI, Breslow JL. Characterization of a unique human apolipoprotein E variant associated with type III hyperlipoproteinemia. J Biol Chem 1980 Mar 10; 255(5): 1759–62
Zannis VI, Breslow JL. Human very low density lipoprotein apolipoprotein E isoprotein polymorphism is explained by genetic variation and posttranslational modification. Biochemistry 1981 Feb 17; 20(4): 1033–41
Davignon J, Gregg RE, Sing CF. Apolipoprotein E polymorphism and atherosclerosis. Arteriosclerosis 1988 Jan–Feb; 8(1): 1–21
Weisgraber KH, Innerarity TL, Mahley RW. Abnormal lipoprotein receptor-binding activity of the human E apoprotein due to cysteine-arginine interchange at a single site. J Biol Chem 1982 Mar 10; 257(5): 2518–21
Ewbank DC. The APOE gene and differences in life expectancy in Europe. J Gerontol A Biol Sci Med Sci 2004 Jan; 59(1): 16–20
Tan CE, Tai ES, Tan CS, et al. APOE polymorphism and lipid profile in three ethnic groups in the Singapore population. Atherosclerosis 2003 Oct; 170(2): 253–60
Seet WT, Mary Anne TJ, Yen TS. Apolipoprotein E genotyping in the Malay, Chinese and Indian ethnic groups in Malaysia-a study on the distribution of the different apoE alleles and genotypes. Clin Chim Acta 2004 Feb; 340(1–2): 201–5
Shearer MJ, McBurney A, Barkhan P. Studies on the absorption and metabolism of phylloquinone (vitamin K1) in man. Vitam Horm 1974; 32: 513–42
Schurgers LJ, Vermeer C. Differential lipoprotein transport pathways of K-vitamins in healthy subjects. Biochim Biophys Acta 2002 Feb 15; 1570(1): 27–32
Lamon-Fava S, Sadowski JA, Davidson KW, et al. Plasma lipoproteins as carriers of phylloquinone (vitamin K1) in humans. Am J Clin Nutr 1998 Jun; 67(6): 1226–31
Erkkila AT, Lichtenstein AH, Dolnikowski GG, et al. Plasma transport of vitamin K in men using deuterium-labeled collard greens. Metabolism 2004 Feb; 53(2): 215–21
Visser LE, Trienekens PH, De Smet PA, et al. Patients with an ApoE epsilon4 allele require lower doses of coumarin anticoagulants. Pharmacogenet Genomics 2005 Feb; 15(2): 69–74
Kohnke H, Scordo MG, Pengo V, et al. Apolipoprotein E (APOE) and warfarin dosing in an Italian population. Eur J Clin Pharmacol 2005 Nov; 61(10): 781–3
Kohnke H, Sorlin K, Granath G, et al. Warfarin dose related to apolipoprotein E (APOE) genotype. Eur J Clin Pharmacol 2005 Jul; 61(5–6): 381–8
Wajih N, Sane DC, Hutson SM, et al. The inhibitory effect of calumenin on the vitamin K-dependent gamma-carboxylation system: characterization of the system in normal and warfarinresistant rats. J Biol Chem 2004; 279(24): 25276–83
Vecsler M, Loebstein R, Almog S, et al. Combined genetic profiles of components and regulators of the vitamin K-dependent gamma-carboxylation system affect individual sensitivity to warfarin. Thromb Haemost 2006; 95(2): 205–11
Loebstein R, Vecsler M, Kurnik D, et al. Common genetic variants of microsomal epoxide hydrolase affect warfarin dose requirements beyond the effect of cytochrome P450 2C9. Clin Pharmacol Ther 2005; 77(5): 365–72
Meyer G, Marjanovic Z, Valcke J, et al. Comparison of lowmolecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med 2002; 162(15): 1729–35
Gage BF, Eby C, Milligan PE, et al. Use of pharmacogenetics and clinical factors to predict the maintenance dose of warfarin. Thromb Haemost 2004; 91(1): 87–94
Acknowledgements
This review was supported by a grant from Singapore Cancer Syndicate (PS0023). The authors have no conflicts of interest that are directly relevant to the content of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lal, S., Jada, S.R., Xiang, X. et al. Pharmacogenetics of Target Genes Across the Warfarin Pharmacological Pathway. Clin Pharmacokinet 45, 1189–1200 (2006). https://doi.org/10.2165/00003088-200645120-00004
Published:
Issue Date:
DOI: https://doi.org/10.2165/00003088-200645120-00004