title: Genetic testing before anticoagulation? A systematic review of pharmacogenetic dosing of warfarin.
abstract: BACKGROUND
  Genotype-guided initial warfarin dosing may reduce over-anticoagulation and serious bleeding compared to a one-dose-fits-all dosing method.
  
  
  OBJECTIVE
  The objective of this review was to investigate the safety and efficacy of genotype-guided dosing of warfarin in reducing the occurrence of serious bleeding events and over-anticoagulation.
  
  
  METHODS
  The authors searched PubMed, EMBASE and International Pharmaceutical Abstracts through January 23, 2009, without language restrictions. Selected articles were randomized trials comparing pharmacogenetic dosing of warfarin versus a "standard" dose control algorithm in adult patients taking warfarin for the first time.
  
  
  METHODS
  Two reviewers independently extracted data and assessed study quality using a validated instrument. The primary outcomes were major bleeding and time spent within the therapeutic range International Normalized Ratio (INR). Secondary outcomes included minor bleeding, thrombotic events and other measures of anticoagulation quality.
  
  
  RESULTS
  Three of 2,014 studies (423 patients) met the inclusion and exclusion criteria. Differences in study quality, dosing algorithms, length of follow-up and outcome measures limited meta-analysis. Summary estimates revealed no statistically significant difference in bleeding rates or time within the therapeutic range INR. The highest quality study found no significant difference in primary or secondary outcomes, although there was a trend towards more rapid achievement of a stable dose (14.1 vs. 19.6 days, p = 0.07) in the pharmocogenetic arm.
  
  
  CONCLUSIONS
  We did not find sufficient evidence to support the use of pharmacogenetics to guide warfarin therapy. Additional clinical trials are needed to define the optimal approach to use warfarin pharmacogenetics in clinical practice.
authors.affiliation: Division of General Internal Medicine, University of California, Box 0131, 533 Parnassus Ave, San Francisco, CA 94143-0131, USA. kkangelaris@medicine.ucsf.edu
authors.forename: Kirsten Neudoerffer
authors.initials: KN
authors.lastname: Kangelaris
authors.forename: Stephen
authors.initials: S
authors.lastname: Bent
authors.forename: Robert L
authors.initials: RL
authors.lastname: Nussbaum
authors.forename: David A
authors.initials: DA
authors.lastname: Garcia
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Tice
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects*; D005820:Genetic Testing / Q000379:methods* / Q000639:trends; D006470:Hemorrhage / Q000139:chemically induced / Q000235:genetics*; D006801:Humans; D019934:International Normalized Ratio; D010597:Pharmacogenetics / Q000379:methods* / Q000639:trends; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014859:Warfarin