title: Should we test for CYP2C9 before initiating anticoagulant therapy in patients with atrial fibrillation?
abstract: BACKGROUND
  Genetic variants of the warfarin sensitivity gene CYP2C9 have been associated with increased bleeding risk during warfarin initiation. Studies also suggest that such patients remain at risk throughout treatment.
  
  
  OBJECTIVE
  Would testing patients with non-valvular atrial fibrillation (AF) for CYP2C9 before initiating warfarin improve outcomes?
  
  
  METHODS
  Markov state transition decision model.
  
  
  METHODS
  Ambulatory or inpatient settings necessitating new initiation of anticoagulation.
  
  
  METHODS
  The base case was a 69-year-old man with newly diagnosed non-valvular AF. Interventions included: (1) warfarin, (2) aspirin, or (3) no antithrombotic therapy without genetic testing; and genetic testing followed by (4) aspirin or (5) no antithrombotic therapy in those with culprit CYP2C9 alleles.
  
  
  METHODS
  Quality-adjusted life years (QALYs).
  
  
  RESULTS
  In the base case, testing and treating patients with CYP2C9*2 and/or CYP2C9*3 with aspirin rather than warfarin was best (8.97 QALYs). However, warfarin without genetic testing was a close second (8.96 QALYs), a difference of roughly 5 days. Sensitivity analyses demonstrated that genetic testing followed by aspirin was best for patients at lower risk of embolic events. Warfarin without testing was preferred if the rate of embolic events was greater than 5% per year, or the risk of major bleeding while receiving warfarin was lower.
  
  
  CONCLUSIONS
  For patients at average risk for ischemic stroke due to AF and at average risk for major hemorrhage, treatment based on genetic testing offers no benefit compared to warfarin initiation without testing. The gain from testing may be larger in patients at lower risk of embolic events or at greater risk of bleeding.
authors.affiliation: Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, University of Cincinnati (MHE), PO Box 670535, Cincinnati, OH 45267-0535, USA. mark.eckman@uc.edu
authors.forename: Mark H
authors.initials: MH
authors.lastname: Eckman
authors.forename: Steven M
authors.initials: SM
authors.lastname: Greenberg
authors.forename: Jonathan
authors.initials: J
authors.lastname: Rosand
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D001189:Aryl Hydrocarbon Hydroxylases / Q000235:genetics*; D001281:Atrial Fibrillation / Q000201:enzymology* / Q000235:genetics*; D065729:Cytochrome P-450 CYP2C9; D006470:Hemorrhage / Q000139:chemically induced / Q000201:enzymology / Q000235:genetics; D006801:Humans; D008297:Male; D008390:Markov Chains; D019057:Quality-Adjusted Life Years
chemical_list: D000925:Anticoagulants; C450260:CYP2C9 protein, human; D065729:Cytochrome P-450 CYP2C9; D001189:Aryl Hydrocarbon Hydroxylases