Protein Information

Name CYP2C9
Synonyms (R) limonene 6 monooxygenase; Xenobiotic monooxygenase; Mephenytoin 4 hydroxylase; Microsomal monooxygenase; S mephenytoin 4 hydroxylase; (S) limonene 6 monooxygenase; (S) limonene 7 monooxygenase; CPC 9…

Compound Information

Name warfarin
CAS

Reference List

PubMed Abstract RScore(About this table)
18922023 Mosher CM, Hummel MA, Tracy TS, Rettie AE: Functional analysis of phenylalanine residues in the active site of cytochrome P450 2C9. Biochemistry. 2008 Nov 11;47(45):11725-34. Epub 2008 Oct 16.

The two published crystal structures of cytochrome P450 2C9, complexed with ( S)-warfarin or flurbiprofen, implicate a cluster of three active site phenylalanine residues (F100, F114, F476) in ligand binding.
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20206792 Muszkat M, Bialer O, Blotnick S, Adar L, Xie HG, Ufer M, Cascorbi I, Caraco Y: Effects of folic acid supplementation on the pharmacokinetics and anticoagulant effect of warfarin: an open-label, prospective study of long-term administration in adults. Clin Ther. 2010 Feb;32(2):347-56.

OBJECTIVE: The aim of this study was to determine whether folic acid supplementation increases the dosage requirement of the CYP2C9 substrate warfarin, and the formation clearance of the CYP2C9-mediated product, (S)-7-hydroxywarfarin.
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18855533 Limdi NA, Beasley TM, Crowley MR, Goldstein JA, Rieder MJ, Flockhart DA, Arnett DK, Acton RT, Liu N: VKORC1 polymorphisms, haplotypes and haplotype groups on warfarin dose among African-Americans and European-Americans. Pharmacogenomics. 2008 Oct;9(10):1445-58.

BACKGROUND: Although the influence of VKORC1 and CYP2C9 polymorphisms on warfarin response has been studied, variability in dose explained by CYP2C9 and VKORC1 is lower among African-Americans compared with European-Americans.
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19745563 Sandanaraj E, Lal S, Cheung YB, Xiang X, Kong MC, Lee LH, Ooi LL, Chowbay B: VKORC1 diplotype-derived dosing model to explain variability in warfarin dose requirements in Asian patients. Drug Metab Pharmacokinet. 2009;24(4):365-75.

The present study identifies the influence of VKORC1 diplotypes, CYP2C9 and CYP2C19 variants on warfarin disposition and dose requirements in Chinese patients (n=107).
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20014877 Meckley LM, Gudgeon JM, Anderson JL, Williams MS, Veenstra DL: A policy model to evaluate the benefits, risks and costs of warfarin pharmacogenomic testing. Pharmacoeconomics. 2010;28(1):61-74. doi: 10.2165/11318240-000000000-00000.

BACKGROUND: In 2007, the US FDA added information about pharmacogenomics to the warfarin label based on the influence of the CYP2C9 and VKORC1 genes on anticoagulation-related outcomes.
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19815307 Meckley LM, Neumann PJ: Personalized medicine: factors influencing reimbursement. Health Policy. 2010 Feb;94(2):91-100. Epub 2009 Oct 7.

METHODS: We conducted six case studies of the following paired genetic tests and treatments: HER2/neu with trastuzumab (Herceptin); hepatitis C genotyping with ribavirin/pegylated interferon; Oncotype DX with chemotherapy; UGT1A1 with irinotecan (Camptosar); VKORC1/CYP2C9 with warfarin; BRCA1/2 with prophylactic surgical measures; and Oncotype DX with chemotherapy.
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19387626 Fuchshuber-Moraes M, Perini JA, Rosskopf D, Suarez-Kurtz G: Exploring warfarin pharmacogenomics with the extreme-discordant-phenotype methodology: impact of FVII polymorphisms on stable anticoagulation with warfarin. Eur J Clin Pharmacol. 2009 Aug;65(8):789-93. Epub 2009 Apr 23.

RESULTS: Significant differences existed in FVII -402G> A genotype frequency at the 5th percentile with an over-representation of the wildtype GG genotype at low warfarin doses and in VKORC1 3673G> A and CYP2C9 polymorphisms at all cutoff points where the variant alleles were overrepresented at low warfarin doses.
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19842940 van Schie RM, Wadelius MI, Kamali F, Daly AK, Manolopoulos VG, de Boer A, Barallon R, Verhoef TI, Kirchheiner J, Haschke-Becher E, Briz M, Rosendaal FR, Redekop WK, Pirmohamed M, van der Zee AH: Genotype-guided dosing of coumarin derivatives: the European pharmacogenetics of anticoagulant therapy (EU-PACT) trial design. Pharmacogenomics. 2009 Oct;10(10):1687-95.

Polymorphisms in VKORC1 and CYP2C9 jointly account for about 40% of the interindividual variability in dose requirements.
To date, several pharmacogenetic-guided dosing algorithms for coumarin derivatives, predominately for warfarin, have been developed.
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19391630 Yasuo K, Yamaotsu N, Gouda H, Tsujishita H, Hirono S: Structure-based CoMFA as a predictive model - CYP2C9 inhibitors as a test case. J Chem Inf Model. 2009 Apr;49(4):853-64.

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19540002 Jonas DE, McLeod HL: Genetic and clinical factors relating to warfarin dosing. Trends Pharmacol Sci. 2009 Jul;30(7):375-86. Epub 2009 Jun 17.

The pivotal role of CYP2C9 and VKORC1 is emphasized because polymorphisms of these two genes account for approximately 40% of the variation in dose requirements.
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18516070 Mohammed Abdul MI, Jiang X, Williams KM, Day RO, Roufogalis BD, Liauw WS, Xu H, McLachlan AJ: Pharmacodynamic interaction of warfarin with cranberry but not with garlic in healthy subjects. Br J Pharmacol. 2008 Aug;154(8):1691-700. Epub 2008 Jun 2.

Both herbal medicines showed some evidence of VKORC1 (not CYP2C9) genotype-dependent interactions with warfarin, which is worthy of further investigation.
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19799531 Perez-Andreu V, Roldan V, Gonzalez-Conejero R, Hernandez-Romero D, Vicente V, Marin F: Implications of pharmacogenetics for oral anticoagulants metabolism. . Curr Drug Metab. 2009 Jul;10(6):632-42.

S-warfarin, predominantly responsible for the anticoagulation effect, is metabolized mostly by the CYP2C9 enzyme.
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19430171 Inoue T, Sugihara K, Ohshita H, Horie T, Kitamura S, Ohta S: Prediction of human disposition toward S-3H-warfarin using chimeric mice with humanized liver. Drug Metab Pharmacokinet. 2009;24(2):153-60.

In this study, we investigated whether these mice show similar metabolic profile to humans by examining the hydroxylation of S-warfarin reported to be mainly metabolized to S-7-hydroxywarfarin (7-OH-warfarin), catalyzed by CYP2C9, in humans.
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20200517 Voora D, Koboldt DC, King CR, Lenzini PA, Eby CS, Porche-Sorbet R, Deych E, Crankshaw M, Milligan PE, McLeod HL, Patel SR, Cavallari LH, Ridker PM, Grice GR, Miller RD, Gage BF: A polymorphism in the VKORC1 regulator calumenin predicts higher warfarin dose requirements in African Americans. Clin Pharmacol Ther. 2010 Apr;87(4):445-51. Epub 2010 Mar 3.

Warfarin demonstrates a wide interindividual variability in response that is mediated partly by variants in cytochrome P450 2C9 (CYP2C9) and vitamin K 2,3-epoxide reductase complex subunit 1 (VKORC1).
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19069171 Takahashi H: [Warfarin resistance and related pharmacogenetic information] . Brain Nerve. 2008 Nov;60(11):1365-71.

Recently genetic factors such as the CYP2C9 and VKORC1 genes have been demonstrated to be determinants of warfarin response.
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18690342 Meckley LM, Wittkowsky AK, Rieder MJ, Rettie AE, Veenstra DL: An analysis of the relative effects of VKORC1 and CYP2C9 variants on anticoagulation related outcomes in warfarin-treated patients. Thromb Haemost. 2008 Aug;100(2):229-39.
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18756910 Samardzija M, Topic E, Stefanovic M, Zibar L, Samardzija G, Balen S, Vcev A, Domanovic D, Mirat J, Barbic J: Association of CYP2C9 gene polymorphism with bleeding as a complication of warfarin therapy. Coll Antropol. 2008 Jun;32(2):557-64.
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19074728 Li C, Schwarz UI, Ritchie MD, Roden DM, Stein CM, Kurnik D: Relative contribution of CYP2C9 and VKORC1 genotypes and early INR response to the prediction of warfarin sensitivity during initiation of therapy. Blood. 2009 Apr 23;113(17):3925-30. Epub 2008 Dec 12.

Genetic variants in CYP2C9 and VKORC1 strongly affect steady-state warfarin dose.
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19389892 Suarez-Kurtz G, Perini JA, Silva-Assuncao E, Struchiner CJ: Relative contribution of VKORC1, CYP2C9, and INR response to warfarin stable dose. Blood. 2009 Apr 23;113(17):4125-6.
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20203262 Limdi NA, Wadelius M, Cavallari L, Eriksson N, Crawford DC, Lee MT, Chen CH, Motsinger-Reif A, Sagreiya H, Liu N, Wu AH, Gage BF, Jorgensen A, Pirmohamed M, Shin JG, Suarez-Kurtz G, Kimmel SE, Johnson JA, Klein TE, Wagner MJ: Warfarin pharmacogenetics: a single VKORC1 polymorphism is predictive of dose across three racial groups. Blood. 2010 Mar 4.

Warfarin dosing algorithms incorporating CYP2C9 and VKORC1-1639G> A improve dose prediction compared to algorithms based solely on clinical and demographic factors.
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18305455 Gage BF, Eby C, Johnson JA, Deych E, Rieder MJ, Ridker PM, Milligan PE, Grice G, Lenzini P, Rettie AE, Aquilante CL, Grosso L, Marsh S, Langaee T, Farnett LE, Voora D, Veenstra DL, Glynn RJ, Barrett A, McLeod HL: Use of pharmacogenetic and clinical factors to predict the therapeutic dose of warfarin. Clin Pharmacol Ther. 2008 Sep;84(3):326-31. Epub 2008 Feb 27.

In the derivation cohort of 1,015 participants, the independent predictors of therapeutic dose were: VKORC1 polymorphism -1639/3673 G> A (-28% per allele), body surface area (BSA) (+11% per 0.25 m (2)), CYP2C9 (*) 3 (-33% per allele), CYP2C9 (*) 2 (-19% per allele), age (-7% per decade), target international normalized ratio (INR) (+11% per 0.5 unit increase), amiodarone use (-22%), smoker status (+10%), race (-9%), and current thrombosis (+7%).
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18701850 Yasui Y, Nishiguchi T, Yamamoto A, Fujii C, Fujino M, Tsuge M, Ohno M, Azuma J, Matsumura T, Ohsato H, Anami S, Furukawa H: [A case of bleeding tendency due to warfarin in a patient treated with chemotherapy by S-1]. Gan To Kagaku Ryoho. 2008 Aug;35(8):1367-70.

We found that he is homozygous for CYP2C9 1/1 and for A/A of VKORC1 (-1639G> A).
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18634396 Sawicka-Powierza J, Rogowska-Szadkowska D, Oltarzewska AM, Chlabicz S: [Factors influencing activity of oral anticoagulants. Pol Merkur Lekarski. 2008 May;24(143):458-62.

A common mutation in the gene coding for the cytochrome P450 (CYP2C9), with one or more combinations of its polymorphisms, is responsible for the reduced warfarin requirements or for the resistance to warfarin.
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18998206 Glurich I, Burmester JK, Caldwell MD: Understanding the pharmacogenetic approach to warfarin dosing. Heart Fail Rev. 2008 Nov 8.

Polymorphic sites in three genes, cytochrome P450 (CYP) 2C9, vitamin K 2,3 epoxide reductase complex 1 (VKORC1), and CYP4F2, have been shown to affect stable warfarin dose.
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18690851 Dumas TE, Hawke RL, Lee CR: Warfarin dosing and the promise of pharmacogenomics. Curr Clin Pharmacol. 2007 Jan;2(1):11-21.

Consistent with in vitro data, clinical studies have demonstrated that CYP2C9 polymorphisms significantly influence warfarin pharmacokinetics by reducing (S)-warfarin metabolic clearance, consequently lowering maintenance dose requirements and increasing the risk over-anticoagulation during the initiation phase of therapy.
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19942260 Yang L, Ge W, Yu F, Zhu H: Impact of VKORC1 gene polymorphism on interindividual and interethnic warfarin dosage requirement--a systematic review and meta analysis. Thromb Res. 2010 Apr;125(4):e159-66. Epub 2009 Nov 25.

It has been suggested that anticoagulation effect of warfarin is significantly associated with the polymorphism of certain genes, including Cytochrome P450 complex subunit 2C9 (CYP2C9), Vitamin K Epoxide Reductase Complex Subunit 1 (VKORC1), Gamma-Glutamyl Carboxylase (GGCX) and Apolipoprotein E (APOE) etc.
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19881396 Salinger DH, Shen DD, Thummel K, Wittkowsky AK, Vicini P, Veenstra DL: Pharmacogenomic trial design: use of a PK/PD model to explore warfarin dosing interventions through clinical trial simulation. Pharmacogenet Genomics. 2009 Oct 29.

OBJECTIVE: Variants of two genes, CYP2C9 and VKORC1, explain approximately one third of variability in warfarin maintenance dose requirements.
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19324988 Langley MR, Booker JK, Evans JP, McLeod HL, Weck KE: Validation of clinical testing for warfarin sensitivity: comparison of CYP2C9-VKORC1 genotyping assays and warfarin-dosing algorithms. J Mol Diagn. 2009 May;11(3):216-25. Epub 2009 Mar 26.
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20210733 Efrati E, Elkin H, Sprecher E, Krivoy N: Distribution of CYP2C9 and VKORC1 Risk Alleles for Warfarin Sensitivity and Resistance in the Israeli Population. Curr Drug Saf. 2010 Mar 7.

Purpose: This study was designed to delineate the relative frequency of CYP2C9 and VKORC1 polymorphisms known to affect warfarin response in the highly heterogeneous Israeli population.
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19453939 Lazo-Langner A, Monkman K, Kovacs MJ: Predicting warfarin maintenance dose in patients with venous thromboembolism based on the response to a standardized warfarin initiation nomogram. J Thromb Haemost. 2009 Aug;7(8):1276-83. Epub 2009 May 12.

BACKGROUND: Polymorphisms in the VKORC1 and CYP2C9 genes influence warfarin requirements.
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19663670 Sasaki T, Tabuchi H, Higuchi S, Ieiri I: Warfarin-dosing algorithm based on a population pharmacokinetic/pharmacodynamic model combined with Bayesian forecasting. Pharmacogenomics. 2009 Aug;10(8):1257-66.

MATERIALS & METHODS: Using information on CYP2C9 and VKORC1 genotypes, S-warfarin level, dose and international normalized ratio (INR) of prothrombin time, individual PK (apparent clearance of S-warfarin [CLs]) and PD (concentration resulting in 50% of E (max) [EC (50)]) parameters were determined by Bayesian forecasting for 45 Japanese patients.
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20140106 Li J, Wang S, Barone J, Malone B: Warfarin pharmacogenomics. P T. 2009 Aug;34(8):422-7.

Achieving safe and effective doses of warfarin therapy is both an urgent and important concern for many clinicians.Recent research has focused on single-nucleotide polymorphisms (SNPs) of genes that encode two proteins: the cytochrome P450 2C9 enzyme and VKORC1 (vitamin K epoxide reductase complex).
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19204416 Guessous I, Gwinn M, Yu W, Yeh J, Clyne M, Khoury MJ: Trends in pharmacogenomic epidemiology: 2001-2007. Public Health Genomics. 2009;12(3):142-8. Epub 2009 Feb 10.

Warfarin was the single most frequently cited drug.
Just 4 genes together accounted for nearly one-fifth of all publications: ABCB1, CYP2C9, CYP2C19, and CYP2D6.
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18381488 Lu C, Berg C, Prakash SR, Lee FW, Balani SK: Prediction of pharmacokinetic drug-drug interactions using human hepatocyte suspension in plasma and cytochrome P450 phenotypic data. Drug Metab Dispos. 2008 Jul;36(7):1261-6. Epub 2008 Apr 1.

Using the available P450 phenotypic information on theophylline, tolbutamide, omeprazole, S-warfarin, phenytoin, cyclosporine, and midazolam and that determined in this study for sirolimus and tacrolimus, we found that the predictions for area under the curve increases for most of these drugs in the presence of fluconazole were remarkably similar (within 35%) to the observed clinical values.
Fluconazole is also a moderate inhibitor of CYP2C9 and CYP2C19.
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19711211 Hauta-Aho M, Tirkkonen T, Vahlberg T, Laine K: The effect of drug interactions on bleeding risk associated with warfarin therapy in hospitalized patients. Ann Med. 2009;41(8):619-28.

Adjusted odds ratio (OR) for bleeding was highest for cytochrome P450 2C9 (CYP2C9) inhibitors (OR 3.6; 95% confidence interval (CI) 2.4-5.6).
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18240910 Wu AH: Use of genetic and nongenetic factors in warfarin dosing algorithms. Pharmacogenomics. 2007 Jul;8(7):851-61.

Recently, polymorphisms in two genes, cytochrome P450 2C9 and vitamin K epoxide reductase complex 1, have been shown to affect warfarin's pharmacogenomics and pharmacodynamics, respectively.
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20095918 Liedtke MD, Rathbun RC: Drug interactions with antiretrovirals and warfarin. . Expert Opin Drug Saf. 2010 Mar;9(2):215-23.

The following search terms were utilized: warfarin, HIV, antiretroviral, drug interaction, protease inhibitor (PI), non-nucleoside reverse-transcriptase inhibitor (NNRTI), cytochrome P450 (CYP450), CYP2C9 and individual antiretrovirals by name.
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20167000 Mo SL, Zhou ZW, Yang LP, Wei MQ, Zhou SF: New insights into the structural features and functional relevance of human cytochrome P450 2C9. Curr Drug Metab. 2009 Dec;10(10):1127-50.

Currently, there are three X-ray structures of the human CYP2C9 in Protein Database (PDB): one ligand-free protein (1OG2), and two in complex with S-warfarin (1OG5) or flurbiprofen (1R9O).
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20233183 Fang ZZ, Zhang YY, Ge GB, Huo H, Liang SC, Yang L: Time-dependent inhibition (TDI) of CYP3A4 and CYP2C9 by noscapine potentially explains clinical noscapine-warfarin interaction. Br J Clin Pharmacol. 2010 Feb;69(2):193-9.
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20072124 Cavallari LH, Langaee TY, Momary KM, Shapiro NL, Nutescu EA, Coty WA, Viana MA, Patel SR, Johnson JA: Genetic and clinical predictors of warfarin dose requirements in African Americans. Clin Pharmacol Ther. 2010 Apr;87(4):459-64. Epub 2010 Jan 13.

The objective of this study was to determine whether, in African-American patients, additional vitamin K oxidoreductase complex subunit 1 (VKORC1), cytochrome P450 2C9 (CYP2C9), CYP4F2, or apolipoprotein E (APOE) polymorphisms contribute to variability in the warfarin maintenance dose beyond what is attributable to the CYP2C9*2 and *3 alleles and the VKORC1 -1639G> A genotype.
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18570163 Ngow H, Teh LK, Langmia IM, Lee WL, Harun R, Ismail R, Salleh MZ: Role of pharmacodiagnostic of CYP2C9 variants in the optimization of warfarin therapy in Malaysia: a 6-month follow-up study. Xenobiotica. 2008 Jun;38(6):641-51.
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19255811 Eckman MH, Greenberg SM, Rosand J: Should we test for CYP2C9 before initiating anticoagulant therapy in patients with atrial fibrillation?. J Gen Intern Med. 2009 May;24(5):543-9. Epub 2009 Mar 3.

BACKGROUND: Genetic variants of the warfarin sensitivity gene CYP2C9 have been associated with increased bleeding risk during warfarin initiation.
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18370846 Wu AH, Wang P, Smith A, Haller C, Drake K, Linder M, Valdes R Jr: Dosing algorithm for warfarin using CYP2C9 and VKORC1 genotyping from a multi-ethnic population: comparison with other equations. Pharmacogenomics. 2008 Feb;9(2):169-78.
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19794411 Pautas E, Moreau C, Gouin-Thibault I, Golmard JL, Mahe I, Legendre C, Taillandier-Heriche E, Durand-Gasselin B, Houllier AM, Verrier P, Beaune P, Loriot MA, Siguret V: Genetic factors (VKORC1, CYP2C9, EPHX1, and CYP4F2) are predictor variables for warfarin response in very elderly, frail inpatients. Clin Pharmacol Ther. 2010 Jan;87(1):57-64. Epub 2009 Sep 30.
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19083245 Goldstein JA, Blaisdell JA, Limdi NA: A potentially deleterious new CYP2C9 polymorphism identified in an African American patient with major hemorrhage on warfarin therapy. Blood Cells Mol Dis. 2009 Mar-Apr;42(2):155-8. Epub 2008 Dec 11.
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18294321 Kulkarni UP, Swar BD, Karnad DR, Davis S, Patwardhan AM, Kshirsagar NA, Gogtay NJ: A pilot study of the association of pharmacokinetic and pharmacodynamic parameters of warfarin with the dose in patients on long-term anticoagulation. Br J Clin Pharmacol. 2008 May;65(5):787-90. Epub 2008 Feb 21.

CYP2C9 and VKORC1 polymorphisms have been shown to affect warfarin dose requirement.
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18662264 Lenzini PA, Grice GR, Milligan PE, Dowd MB, Subherwal S, Deych E, Eby CS, King CR, Porche-Sorbet RM, Murphy CV, Marchand R, Millican EA, Barrack RL, Clohisy JC, Kronquist K, Gatchel SK, Gage BF: Laboratory and clinical outcomes of pharmacogenetic vs. clinical protocols for warfarin initiation in orthopedic patients. J Thromb Haemost. 2008 Oct;6(10):1655-62. Epub 2008 Jul 24.

RESULTS: The pharmacogenetic algorithm used the cytochrome P450 (CYP) 2C9 genotype, smoking status, peri-operative blood loss, liver disease, INR values and dose history to predict the therapeutic dose.
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18673195 Di YM, Li CG, Xue CC, Zhou SF: Clinical drugs that interact with St. Curr Pharm Des. 2008;14(17):1723-42.

CYP2C9 and 3A4) and P-glycoprotein (P-gp) are considered the major mechanism.
A number of clinically significant interactions of SJW have been identified with conventional drugs, including anticancer agents (imatinib and irinotecan), anti-HIV agents (e.g. indinavir, lamivudine and nevirapine), anti-inflammatory agents (e.g. ibuprofen and fexofenadine), antimicrobial agents (e.g. erythromycin and voriconazole), cardiovascular drugs (e.g. digoxin, ivabradine, warfarin, verapamil, nifedipine and talinolol), central nervous system agents (e.g. amitriptyline, buspirone, phenytoin, methadone, midazolam, alprazolam, and sertraline), hypoglycaemic agents (e.g. tolbutamide and gliclazide), immuno-modulating agents (e.g. cyclosporine and tacrolimus), oral contraceptives, proton pump inhibitor (e.g. omeprazole), respiratory system agent (e.g. theophylline), statins (e.g. atorvastatin and pravastatin).
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19270263 Perez-Andreu V, Roldan V, Anton AI, Garcia-Barbera N, Corral J, Vicente V, Gonzalez-Conejero R: Pharmacogenetic relevance of CYP4F2 V433M polymorphism on acenocoumarol therapy. Blood. 2009 May 14;113(20):4977-9. Epub 2009 Mar 6.

VKORC1 and CYP2C9 polymorphisms are used to predict the safe dose of oral anticoagulant therapy.
A new variant of CYP4F2 (V433M) has recently been related to the required warfarin dose.
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18788834 Shen AY, Chen W, Yao JF, Brar SS, Wang X, Go AS: Effect of race/ethnicity on the efficacy of warfarin: potential implications for prevention of stroke in patients with atrial fibrillation. CNS Drugs. 2008;22(10):815-25.

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20147896 Dumond JB, Vourvahis M, Rezk NL, Patterson KB, Tien HC, White N, Jennings SH, Choi SO, Li J, Wagner MJ, La-Beck NM, Drulak M, Sabo JP, Castles MA, Macgregor TR, Kashuba AD: A Phenotype-Genotype Approach to Predicting CYP450 and P-Glycoprotein Drug Interactions With the Mixed Inhibitor/Inducer Tipranavir/Ritonavir. Clin Pharmacol Ther. 2010 Feb 10.


The subjects received oral (p.o.) caffeine, warfarin + vitamin K, omeprazole, dextromethorphan, and midazolam and digoxin (p.o. and intravenous (i.v.)) at baseline, during the first three doses of TPV/r (500 mg/200 mg b.i.d.), and at steady state.
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18466099 Limdi NA, Arnett DK, Goldstein JA, Beasley TM, McGwin G, Adler BK, Acton RT: Influence of CYP2C9 and VKORC1 on warfarin dose, anticoagulation attainment and maintenance among European-Americans and African-Americans. Pharmacogenomics. 2008 May;9(5):511-26.

AIMS: The influence of CYP2C9 and VKORC1 on warfarin dose, time to target International Normalized Ratio (INR), time to stabilization, and risk of over-anticoagulation (INR: > 4) was assessed after adjustment for clinical factors, intraindividual variation in environmental factors and unobserved heterogeneity.
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19495518 Ngow HA, Wan Khairina WM, Teh LK, Lee WL, Harun R, Ismail R, Salleh MZ: CYP2C9 polymorphism: prevalence in healthy and warfarin-treated Malay and Chinese in Malaysia. Singapore Med J. 2009 May;50(5):490-3.

CYP2C9 has been reported to be the enzyme responsible for the metabolism of many drugs, including warfarin and other drugs with a narrow therapeutic index.
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18574025 Wadelius M, Chen LY, Lindh JD, Eriksson N, Ghori MJ, Bumpstead S, Holm L, McGinnis R, Rane A, Deloukas P: The largest prospective warfarin-treated cohort supports genetic forecasting. Blood. 2009 Jan 22;113(4):784-92. Epub 2008 Jun 23.

A multiple regression model using the predictors CYP2C9, VKORC1, age, sex, and druginteractions explained 59% of the variance in warfarin dose, and 53% in an independent sample of 181 Swedish individuals.
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18281915 McClain MR, Palomaki GE, Piper M, Haddow JE: A rapid-ACCE review of CYP2C9 and VKORC1 alleles testing to inform warfarin dosing in adults at elevated risk for thrombotic events to avoid serious bleeding. Genet Med. 2008 Feb;10(2):89-98.
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18752379 Limdi NA, Veenstra DL: Warfarin pharmacogenetics. Pharmacotherapy. 2008 Sep;28(9):1084-97.

We review the evidence of the influence of the two key genes of interest, the cytochrome P450 2C9 gene, CYP2C9, and the vitamin K epoxide reductase complex 1 gene, VKORC1, on warfarin response and discuss the implications of current knowledge for clinical practice.
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19582440 Ohno M, Yamamoto A, Ono A, Miura G, Funamoto M, Takemoto Y, Otsu K, Kouno Y, Tanabe T, Masunaga Y, Nonen S, Fujio Y, Azuma J: Influence of clinical and genetic factors on warfarin dose requirements among Japanese patients. Eur J Clin Pharmacol. 2009 Nov;65(11):1097-103. Epub 2009 Jul 7.

PCR-based methods were performed to analyze genetic polymorphisms in the genes pharmacokinetically and pharmacodynamically related to warfarin reactions, including cytochrome P450 (CYP) 2C9, vitamin K epoxide reductase complex subunit 1 (VKORC1), gamma-glutamyl carboxylase (GGCX) and factor VII (FVII).
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19855097 Chaudhry AS, Urban TJ, Lamba JK, Birnbaum AK, Remmel RP, Subramanian M, Strom S, You JH, Kasperaviciute D, Catarino CB, Radtke RA, Sisodiya SM, Goldstein DB, Schuetz EG: CYP2C9*1B promoter polymorphisms, in linkage with CYP2C19*2, affect phenytoin autoinduction of clearance and maintenance dose. J Pharmacol Exp Ther. 2010 Feb;332(2):599-611. Epub 2009 Oct 23.

The commonly prescribed antiepileptic drug phenytoin has a narrow therapeutic range and wide interindividual variability in clearance explained in part by CYP2C9 and CYP2C19 coding variants.
These rPMs explained as much as 10% of the variation in phenytoin maintenance dose in epileptic patients, but were not correlated with other patients' warfarin dose requirements or with phenytoin metabolite ratio in human liver microsomes.
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19686083 Kamali F, Wynne H: Pharmacogenetics of warfarin. . Annu Rev Med. 2010;61:63-75.

Single nucleotide polymorphisms in the cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase (VKOR) genes have been shown to have a significant effect on warfarin dose requirement.
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20073138 Duconge J, Cadilla CL, Windemuth A, Kocherla M, Gorowski K, Seip RL, Bogaard K, Renta JY, Piovanetti P, D'Agostino D, Santiago-Borrero PJ, Ruano G: Prevalence of combinatorial CYP2C9 and VKORC1 genotypes in Puerto Ricans: implications for warfarin management in Hispanics. Ethn Dis. 2009 Autumn;19(4):390-5.

Combinatorial genotyping of CYP2C9 and VKORC1 can allow for individualized dosing of warfarin among patients with gene polymorphisms, potentially reducing the risk of stroke or bleeding.
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19099951 Yang J, Miao LY, Huang CR, Shen ZY, Jiang WP: [Association between CYP2C9 and VKORC1 genetic polymorphism and warfarin dose requirements]. Zhonghua Xin Xue Guan Bing Za Zhi. 2008 Feb;36(2):137-40.

CONCLUSION: This study showed that age, weight and VKORC1 and CYP2C9 polymorphism had significant influences on warfarin dose requirements and should be considered on dosing regimens modification to improve the safety of warfarin therapy.
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19874474 Ferder NS, Eby CS, Deych E, Harris JK, Ridker PM, Milligan PE, Goldhaber SZ, King CR, Giri T, McLeod HL, Glynn RJ, Gage BF: Ability of VKORC1 and CYP2C9 to predict therapeutic warfarin dose during the initial weeks of therapy. J Thromb Haemost. 2010 Jan;8(1):95-100. Epub 2009 Oct 30.
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18682545 Hynicka LM, Cahoon WD Jr, Bukaveckas BL: Genetic testing for warfarin therapy initiation. Ann Pharmacother. 2008 Sep;42(9):1298-303. Epub 2008 Aug 5.

DATA SOURCES: Searches of MEDLINE (1966-May 2008) and Cochrane Database (1993-May 2008) were conducted using the search terms warfarin, anticoagulation, pharmacogenomics, pharmacogenetics, CYP2C9, VKORC1, and interindividual variability.
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18429757 Mikheeva IuA, Kropacheva ES, Ignat'ev IV, Bulytova IuM, Ramenskaia GV, Sychev DA, Dobrovol'skii AB, Panchenko EP: [Cytochrome P4502C9 (CYP2C9) gene polymorphism and safety of therapy with warfarin]. Kardiologiia. 2008;48(3):52-7.
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20128861 Lubitz SA, Scott SA, Rothlauf EB, Agarwal A, Peter I, Doheny D, van der Zee S, Jaremko M, Yoo C, Desnick RJ, Halperin JL: Comparative performance of gene-based warfarin dosing algorithms in a multiethnic population. J Thromb Haemost. 2010 Feb 2.

Patients/methods: In 145 compliant patients on warfarin with a goal INR of 2-3, stable, therapeutic doses were compared to predicted doses using 12 reported algorithms that incorporated CYP2C9 and VKORC1 variants.
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18754001 Perini JA, Struchiner CJ, Silva-Assuncao E, Santana IS, Rangel F, Ojopi EB, Dias-Neto E, Suarez-Kurtz G: Pharmacogenetics of warfarin: development of a dosing algorithm for brazilian patients. Clin Pharmacol Ther. 2008 Dec;84(6):722-8. Epub 2008 Aug 27.

A dosing algorithm including genetic (VKORC1 and CYP2C9 genotypes) and nongenetic factors (age, weight, therapeutic indication, and cotreatment with amiodarone or simvastatin) explained 51% of the variance in stable weekly warfarin doses in 390 patients attending an anticoagulant clinic in a Brazilian public hospital.
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19032008 Lackner TE: Pharmacogenomic dosing of warfarin: ready or not? . Consult Pharm. 2008 Aug;23(8):614-9.

Following completion of the Human Genome Project, several genetic variants of CYP2C9 and VKORC1 have been identified that account for a greater proportion of the variability in patient response to warfarin than is explained by nongenetic factors.
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20354686 Molden E, Okkenhaug C, Ekker Solberg E: Increased frequency of CYP2C9 variant alleles and homozygous VKORC1*2B carriers in warfarin-treated patients with excessive INR response. Eur J Clin Pharmacol. 2010 Mar 31.

BACKGROUND: Several studies have linked mutations in the genes encoding cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase complex 1 (VKORC1) to a reduced warfarin dose requirement and an increased risk of bleeding with warfarin treatment, but the implementation of genotyping as routine practice is still controversial.
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19679631 Linder MW, Bon Homme M, Reynolds KK, Gage BF, Eby C, Silvestrov N, Valdes R Jr: Interactive modeling for ongoing utility of pharmacogenetic diagnostic testing: application for warfarin therapy. Clin Chem. 2009 Oct;55(10):1861-8. Epub 2009 Aug 13.

CONCLUSIONS: The target interval of plasma S-warfarin concentration required to yield a therapeutic INR can be predicted from the VKORC1 genotype (pharmacodynamics), and the progressive changes in S-warfarin concentration after repeated daily dosing can be predicted from the CYP2C9 genotype (pharmacokinetics).
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19899329 Ghadam P, Sharifian R, Farsangi ZJ, Kianmehr Z, Lak M: CYP2C9 gene analysis of some Iranian hypersensitive patients to warfarin. . Pak J Biol Sci. 2009 Aug 15;12(16):1160-3.
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19571807 You JH, Tsui KK, Wong RS, Cheng G: Potential clinical and economic outcomes of CYP2C9 and VKORC1 genotype-guided dosing in patients starting warfarin therapy. Clin Pharmacol Ther. 2009 Nov;86(5):540-7. Epub 2009 Jul 1.
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20031873 Patrick AR, Avorn J, Choudhry NK: Cost-effectiveness of genotype-guided warfarin dosing for patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2009 Sep;2(5):429-36. Epub 2009 Jul 21.

BACKGROUND: CYP2C9 and VKORC1 genotyping has been advocated as a means of improving the accuracy of warfarin dosing.
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20204461 Shaw PB, Donovan JL, Tran MT, Lemon SC, Burgwinkle P, Gore J: Accuracy assessment of pharmacogenetically predictive warfarin dosing algorithms in patients of an academic medical center anticoagulation clinic. J Thromb Thrombolysis. 2010 Mar 5.

Seventy-one patients of an outpatient anticoagulation clinic at an academic medical center who were age 18 years or older on a stable, therapeutic warfarin dose with international normalized ratio (INR) goal between 2.0 and 3.0, and cytochrome P450 isoenzyme 2C9 (CYP2C9) and vitamin K epoxide reductase complex subunit 1 (VKORC1) genotypes available between January 1, 2007 and September 30, 2008 were included.
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18281922 Flockhart DA, O'Kane D, Williams MS, Watson MS, Flockhart DA, Gage B, Gandolfi R, King R, Lyon E, Nussbaum R, O'Kane D, Schulman K, Veenstra D, Williams MS, Watson MS: Pharmacogenetic testing of CYP2C9 and VKORC1 alleles for warfarin. . Genet Med. 2008 Feb;10(2):139-50.

In an effort to address this situation, a multidisciplinary expert group was organized in November 2006 to evaluate the role of CYP2C9 and VKORC1 testing in altering warfarin-related therapeutic goals and reduction of adverse drug events.
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19925388 Wang B, Wang J, Huang SQ, Su HH, Zhou SF: Genetic Polymorphism of the Human Cytochrome P450 2C9 Gene and Its Clinical Significance. Curr Drug Metab. 2009 Sep;10(7):781-834.

Human cytochrome P450 2C9 (CYP2C9) accounts for approximately 20% of total hepatic CYP content and metabolizes approximately 15% clinically used drugs including S-warfarin, tolbutamide, phenytoin, losartan, diclofenac, and celecoxib.
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19958090 Lee MT, Chen CH, Chou CH, Lu LS, Chuang HP, Chen YT, Saleem AN, Wen MS, Chen JJ, Wu JY, Chen YT: Genetic determinants of warfarin dosing in the Han-Chinese population. Pharmacogenomics. 2009 Dec;10(12):1905-13.

Polymorphisms in CYP2C9 and VKORC1 have been shown to be associated with warfarin dose requirements.
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19181737 Aomori T, Yamamoto K, Oguchi-Katayama A, Kawai Y, Ishidao T, Mitani Y, Kogo Y, Lezhava A, Fujita Y, Obayashi K, Nakamura K, Kohnke H, Wadelius M, Ekstrom L, Skogastierna C, Rane A, Kurabayashi M, Murakami M, Cizdziel PE, Hayashizaki Y, Horiuchi R: Rapid single-nucleotide polymorphism detection of cytochrome P450 (CYP2C9) and vitamin K epoxide reductase (VKORC1) genes for the warfarin dose adjustment by the SMart-amplification process version 2. Clin Chem. 2009 Apr;55(4):804-12. Epub 2009 Jan 30.
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19179293 Kim MJ, Huang SM, Meyer UA, Rahman A, Lesko LJ: A regulatory science perspective on warfarin therapy: a pharmacogenetic opportunity. J Clin Pharmacol. 2009 Feb;49(2):138-46.

A substantial number of studies demonstrate that common variants of two genes, VKORC1 and CYP2C9, along with other nongenetic factors, correlate significantly with warfarin dosing.
12(0,0,2,2) Details
19530963 Becquemont L: Pharmacogenomics of adverse drug reactions: practical applications and perspectives. Pharmacogenomics. 2009 Jun;10(6):961-9.

Recently published pharmacogenomic randomized, controlled and ongoing trials will progressively make genotyping tests, such as those for HLA-B*5701 (abacavir), TPMT (6-mercaptopurine), CYP2C9 plus VKORC1 (warfarin) and CYP3A5 (tacrolimus), mandatory.
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19074529 Si D, Wang Y, Zhou YH, Guo Y, Wang J, Zhou H, Li ZS, Fawcett JP: Mechanism of CYP2C9 inhibition by flavones and flavonols. Drug Metab Dispos. 2009 Mar;37(3):629-34. Epub 2008 Dec 12.

Computer docking simulation and constructed mutants substituted at residue 100 of CYP2C9.1 indicate that the noncompetitive binding site of 6-hydroxyflavone lies beside Phe100, similar to the reported allosteric binding site of warfarin.
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19297219 Limdi NA, Wiener H, Goldstein JA, Acton RT, Beasley TM: Influence of CYP2C9 and VKORC1 on warfarin response during initiation of therapy. Blood Cells Mol Dis. 2009 Jul-Aug;43(1):119-28. Epub 2009 Mar 17.

BACKGROUND: Although multiple reports have documented the influence of CYP2C9 and VKORC1 variants on warfarin dose, risk of over-anticoagulation and hemorrhage, their influence on anticoagulation maintenance and individual proportion of time spent in target INR range (PPTR) is limited.
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19515014 Zhou SF, Zhou ZW, Yang LP, Cai JP: Substrates, inducers, inhibitors and structure-activity relationships of human Cytochrome P450 2C9 and implications in drug development. Curr Med Chem. 2009;16(27):3480-675. Epub 2009 Sep 1.

CYP2C9 metabolizes more than 100 therapeutic drugs, including tolbutamide, glyburide, diclofenac, celecoxib, torasemide, phenytoin losartan, and S-warfarin).
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18680736 Wang TL, Li HL, Tjong WY, Chen QS, Wu GS, Zhu HT, Hou ZS, Xu S, Ma SJ, Wu M, Tai S: Genetic factors contribute to patient-specific warfarin dose for Han Chinese. Clin Chim Acta. 2008 Oct;396(1-2):76-9. Epub 2008 Jul 12.

The associations of SNPs rs9934438 and rs9923231 of VKORC1, the 3 (rs1057910) and C (-65) (rs9332127) alleles of CYP2C9, and SNP rs4653436 of EPHXI with the dose of warfarin were significant.
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20043560 Kuanprasert S, Dettrairat S, Palacajornsuk P, Kunachiwa W, Phrommintikul A: Prevalence of CYP2C9 and VKORC1 mutation in patients with valvular heart disease in northern Thailand. J Med Assoc Thai. 2009 Dec;92(12):1597-601.

Vitamin K epoxide reductase (VKORC1) and cytochrome P450 2C9 (CYP2C9) enzyme conjointly determine the warfarin maintenance dose.
10(0,0,1,5) Details
19381164 Sanchez-Diz P, Estany-Gestal A, Aguirre C, Blanco A, Carracedo A, Ibanez L, Passiu M, Provezza L, Ramos-Ruiz R, Ruiz B, Salado-Valdivieso I, Velasco EA, Figueiras A: Prevalence of CYP2C9 polymorphisms in the south of Europe. Pharmacogenomics J. 2009 Oct;9(5):306-10. Epub 2009 Apr 21.

The results obtained show that above 40% of our samples carry a mutate allele, which can result in a poor metabolization of low therapeutic index drugs as oral anticoagulants (warfarin, acenocoumarol), oral antidiabetic drugs and some non-steroidal anti-inflammatory drugs.
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19082874 Kusama M, Maeda K, Chiba K, Aoyama A, Sugiyama Y: Prediction of the effects of genetic polymorphism on the pharmacokinetics of CYP2C9 substrates from in vitro data. Pharm Res. 2009 Apr;26(4):822-35. Epub 2008 Dec 12.

RESULTS: Sufficient data were available for nine substrates: celecoxib, diclofenac, S-flurbiprofen, losartan, S-phenprocoumon, phenytoin, tolbutamide, torsemide, and S-warfarin.
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18322281 Schwarz UI, Ritchie MD, Bradford Y, Li C, Dudek SM, Frye-Anderson A, Kim RB, Roden DM, Stein CM: Genetic determinants of response to warfarin during initial anticoagulation. N Engl J Med. 2008 Mar 6;358(10):999-1008.

CONCLUSIONS: Initial variability in the INR response to warfarin was more strongly associated with genetic variability in the pharmacologic target of warfarin, VKORC1, than with CYP2C9.
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19117406 Huang SW, Li Q, Zhu SY, Li L, Xiong F, Jia YK, Xu XM: SYBR Green-based real-time PCR assay for detection of VKORC1 and CYP2C9 polymorphisms that modulate warfarin dose requirement. Clin Chem Lab Med. 2009;47(1):26-31.
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20002088 Turpault S, Brian W, Van Horn R, Santoni A, Poitiers F, Donazzolo Y, Boulenc X: Pharmacokinetic assessment of a five-probe cocktail for CYPs 1A2, 2C9, 2C19, 2D6 and 3A. Br J Clin Pharmacol. 2009 Dec;68(6):928-35.

AIMS: To assess the pharmacokinetics (PK) of selective substrates of CYP1A2 (caffeine), CYP2C9 (S-warfarin), CYP2C19 (omeprazole), CYP2D6 (metoprolol) and CYP3A (midazolam) when administered orally and concurrently as a cocktail relative to the drugs administered alone.
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19348697 Daly AK: Pharmacogenomics of anticoagulants: steps toward personal dosage. Genome Med. 2009 Jan 21;1(1):10.

Genotype for CYP2C9, which encodes the main cytochrome P450 enzyme that metabolizes warfarin, and VKORC1, the gene encoding the warfarin target vitamin K epoxide reductase, together account for approximately 30% of the variability in dose requirement.
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19319511 Werner D, Werner U, Wuerfel A, Grosch A, Lestin HG, Eschenhagen T, Rau T: Pharmacogenetic characteristics of patients with complicated phenprocoumon dosing. Eur J Clin Pharmacol. 2009 Aug;65(8):783-8. Epub 2009 Mar 25.

Whereas the impacts of the cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase (VKORC1) polymorphisms on warfarin dosing are clearly established, the role of these genetic variants on dosing and the safe use of phenprocoumon are less well investigated and, to a certain degree, controversial.
9(0,0,1,4) Details
20226775 Maurice CB, Barua PK, Simses D, Smith P, Howe JG, Stack G: Comparison of assay systems for warfarin-related CYP2C9 and VKORC1 genotyping. Clin Chim Acta. 2010 Mar 11.
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19567378 Palacio L, Falla D, Tobon I, Mejia F, Lewis JE, Martinez AF, Arcos-Burgos M, Camargo M: Pharmacogenetic impact of VKORC1 and CYP2C9 allelic variants on warfarin dose requirements in a hispanic population isolate. Clin Appl Thromb Hemost. 2010 Feb;16(1):83-90. Epub 2009 Jun 29.
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19132230 Beinema M, Brouwers JR, Schalekamp T, Wilffert B: Pharmacogenetic differences between warfarin, acenocoumarol and phenprocoumon. Thromb Haemost. 2008 Dec;100(6):1052-7.

Yet it has been proven that variant alleles of the VKORC1 and CYP2C9 genotypes influence the pharmacokinetics and pharmacodynamics of these drugs.
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18698879 Stehle S, Kirchheiner J, Lazar A, Fuhr U: Pharmacogenetics of oral anticoagulants: a basis for dose individualization. Clin Pharmacokinet. 2008;47(9):565-94.

Coumarin derivatives, including warfarin, acenocoumarol and phenprocoumon, are the drugs of choice for long-term treatment and prevention of thromboembolic events.
Cytochrome P450 (CYP) 2C9, which is the main enzyme for rate-limiting metabolism of oral anticoagulants, had the largest impact on the dose demand.
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19464879 Yong WP, Kim TW, Undevia SD, Innocenti F, Ratain MJ: R (+) XK469 inhibits hydroxylation of S-warfarin by CYP2C9. . Eur J Cancer. 2009 Jul;45(11):1904-8. Epub 2009 May 21.
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19017829 Bird J, Carmona C: Probable interaction between warfarin and torsemide. . Ann Pharmacother. 2008 Dec;42(12):1893-8. Epub 2008 Nov 18.

OBJECTIVE: To report a case in which the anticoagulation effect of warfarin appeared to be potentiated by torsemide, possibly due to an interference of metabolism through competition for the CYP2C9 isoenzyme and protein-binding displacement of warfarin.
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19196837 Liedtke MD, Rathbun RC: Warfarin-antiretroviral interactions. . Ann Pharmacother. 2009 Feb;43(2):322-8. Epub 2009 Feb 5.

DATA SOURCES: Primary literature was identified through a search of MEDLINE (1950-July 2008) and International Pharmaceutical Abstracts (1970-July 2008) using individual antiretroviral drug names and the following key search terms: warfarin, antiretroviral, protease inhibitor, nonnucleoside reverse transcriptase inhibitor, cytochrome P450, 2C9, HIV, and drug interactions.
193(2,3,3,3) Details
19715737 Zhou SF, Zhou ZW, Huang M: Polymorphisms of human cytochrome P450 2C9 and the functional relevance. Toxicology. 2009 Aug 26.

Human cytochrome P450 2C9 (CYP2C9) accounts for approximately 20% of hepatic total CYP content and metabolizes approximately 15% clinical drugs such as phenytoin, S-warfarin, tolbutamide, losartan, and many nonsteroidal anti-inflammatory agents (NSAIDs).
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18576910 Fulco PP, Zingone MM, Higginson RT: Possible antiretroviral therapy-warfarin drug interaction. . Pharmacotherapy. 2008 Jul;28(7):945-9.

Warfarin has two enantiomers, R-and S-warfarin, which are substrates primarily of cytochrome P450 (CYP) 3A4 (R-warfarin), CYP1A2 (R-warfarin), and CYP2C9 (S-warfarin).
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19207028 Borgiani P, Ciccacci C, Forte V, Sirianni E, Novelli L, Bramanti P, Novelli G: CYP4F2 genetic variant (rs2108622) significantly contributes to warfarin dosing variability in the Italian population. Pharmacogenomics. 2009 Feb;10(2):261-6.

AIMS: The aim of our work was to replicate this study in the Italian population and to assess the new CYP4F2 variant relative contribution in explaining warfarin dose variability with respect to CYP2C9 and VKORC1 genetic variants together with age and weight.
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18480003 King CR, Porche-Sorbet RM, Gage BF, Ridker PM, Renaud Y, Phillips MS, Eby C: Performance of commercial platforms for rapid genotyping of polymorphisms affecting warfarin dose. Am J Clin Pathol. 2008 Jun;129(6):876-83.

Pharmacogenetic-based dosing algorithms can improve accuracy of initial warfarin dosing but require rapid genotyping for cytochrome P-450 2C9 (CYP2C9) *2 and *3 single nucleotide polymorphisms (SNPs) and a vitamin K epoxide reductase (VKORC1) SNP.
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20117066 Kaur-Knudsen D, Nordestgaard BG, Bojesen SE: CYP2C9 genotype does not affect risk of tobacco-related cancer in the general population. Cancer Epidemiol. 2010 Jan 28.

Background: CYP2C9 enzymes are important in the metabolism of procarcinogenic chemicals such as polycyclic aromatic hydrocarbons (PAHs) found in tobacco smoke.
Two functional variants in the CYP2C9 gene (CYP2C9*2 and CYP2C9*3) are known to be associated with decreased enzyme activity towards tolbutamide and warfarin, while this has not been investigated for PAHs.
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20020283 Cadamuro J, Dieplinger B, Felder T, Kedenko I, Mueller T, Haltmayer M, Patsch W, Oberkofler H: Genetic determinants of acenocoumarol and phenprocoumon maintenance dose requirements. Eur J Clin Pharmacol. 2010 Mar;66(3):253-60. Epub 2009 Dec 18.

OBJECTIVE: The variability in warfarin dose requirement is attributable to genetic and environmental factors.
METHODS: Common single nucleotide polymorphisms (SNPs) in the genes encoding cytochrome P450 family member 2C9 (CYP2C9), vitamin K epoxide reductase complex subunit 1 (VKORC1), gamma-glutamyl carboxylase (GGCX), calumenin (CALU) and apolipoprotein E (APOE) were studied in 206 patients receiving AC or PC.
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19578179 Teichert M, Eijgelsheim M, Rivadeneira F, Uitterlinden AG, van Schaik RH, Hofman A, De Smet PA, van Gelder T, Visser LE, Stricker BH: A genome-wide association study of acenocoumarol maintenance dosage. Hum Mol Genet. 2009 Oct 1;18(19):3758-68. Epub 2009 Jul 4.

The lowest P-value on chromosome 10 was obtained by rs4086116 within cytochrome P450 2C9 (CYP2C9) (P = 3.3 x 10 (-24)).
Several genome-wide association studies have been performed on warfarin.
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19171677 Yang M, Kabulski JL, Wollenberg L, Chen X, Subramanian M, Tracy TS, Lederman D, Gannett PM, Wu N: Electrocatalytic drug metabolism by CYP2C9 bonded to a self-assembled monolayer-modified electrode. Drug Metab Dispos. 2009 Apr;37(4):892-9. Epub 2009 Jan 26.

In summary, the CYP2C9-SAM-gold electrode system was able to carry out the metabolism of warfarin only after application of an electrical potential, but in the absence of either CPR or NADPH.
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19843839 Givens CB, Bullock LN, Franks AS: Safety of concomitant tamoxifen and warfarin. . Ann Pharmacother. 2009 Nov;43(11):1867-71. Epub 2009 Oct 20.

DATA SOURCES: A search of MEDLINE from 1948 to August 20, 2009, was performed using the search terms tamoxifen, warfarin, drug interactions, and cytochrome P450 2C9.
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19995889 Mwinyi J, Nekvindova J, Cavaco I, Hofmann Y, Pedersen RS, Landman E, Mkrtchian S, Ingelman-Sundberg M: New insights into the regulation of CYP2C9 gene expression: the role of the transcription factor GATA-4. Drug Metab Dispos. 2010 Mar;38(3):415-21. Epub 2009 Dec 7.

CYP2C9 is an important drug-metabolizing enzyme that metabolizes, e.g., warfarin, antidiabetics, and antiphlogistics.
37(0,1,1,7) Details
19077919 Kim HS, Lee SS, Oh M, Jang YJ, Kim EY, Han IY, Cho KH, Shin JG: Effect of CYP2C9 and VKORC1 genotypes on early-phase and steady-state warfarin dosing in Korean patients with mechanical heart valve replacement. Pharmacogenet Genomics. 2009 Feb;19(2):103-12.
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19378397 Masek V, Anzenbacherova E, Machova M, Brabec V, Anzenbacher P: Interaction of antitumor platinum complexes with human liver microsomal cytochromes P450. Anticancer Drugs. 2009 Jun;20(5):305-11.

Interestingly, clinically non-significant inhibition was found with the CYP2C9 and CYP2C8 indicating low probability of interactions with, for example, warfarin.
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20017677 Zhu J, Zhang W, Li Y, Zhang W, Wang H, Zheng W, Wang C: ARMS test for diagnosis of CYP2C9 and VKORC1 mutation in patients with pulmonary embolism in Han Chinese. Pharmacogenomics. 2010 Jan;11(1):113-9.

AIMS: VKORC1 and CYP2C9 are important genetic factors affecting warfarin dose requirement.
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19752777 Jorgensen AL, Al-Zubiedi S, Zhang JE, Keniry A, Hanson A, Hughes DA, Eker D, Stevens L, Hawkins K, Toh CH, Kamali F, Daly AK, Fitzmaurice D, Coffey A, Williamson PR, Park BK, Deloukas P, Pirmohamed M: Genetic and environmental factors determining clinical outcomes and cost of warfarin therapy: a prospective study. Pharmacogenet Genomics. 2009 Oct;19(10):800-12.

BACKGROUND: In this prospective cohort study, we have undertaken a comprehensive evaluation of clinical parameters along with variation in 29 genes (including CYP2C9 and VKORC1) to identify factors determining interindividual variability in warfarin response.
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18855611 Zhou SF, Di YM, Chan E, Du YM, Chow VD, Xue CC, Lai X, Wang JC, Li CG, Tian M, Duan W: Clinical pharmacogenetics and potential application in personalized medicine. Curr Drug Metab. 2008 Oct;9(8):738-84.

For example, warfarin serves as a good practical example of how pharmacogenetics can be utilized prior to commencement of therapy in order to achieve maximum efficacy and minimum toxicity.
CYP2D6, CYP2C19 and CYP2C9 gene polymorphisms and gene duplications account for the most frequent variations in phase I metabolism of drugs since nearly 80% of drugs in use today are metabolised by these enzymes.
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19998810 Cortez-Dias N, Correia MJ, Coutinho A, Fernandes C, Diogo AN, Lopes MG: Pharmacogenetics and anticoagulant therapy: two cases of genetically determined response to warfarin. Rev Port Cardiol. 2009 Sep;28(9):995-1004.

The genetic variants c.430CC and c.1075AA of the CYP2C9 gene were identified, predisposing to rapid warfarin metabolism, as well as the c.-1639GG variant of the VKORC1 gene, associated with low sensitivity to the drug.
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18559094 Haug KB, Sharikabad MN, Kringen MK, Narum S, Sjaatil ST, Johansen PW, Kierulf P, Seljeflot I, Arnesen H, Brors O: Warfarin dose and INR related to genotypes of CYP2C9 and VKORC1 in patients with myocardial infarction. Thromb J. 2008 Jun 17;6:7.

Individual dosage requirement has recently partly been explained by genetic variation of the warfarin metabolizing enzyme CYP2C9 and the Vitamin K-activating enzyme VKORC1.
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19663669 Scott SA, Jaremko M, Lubitz SA, Kornreich R, Halperin JL, Desnick RJ: CYP2C9*8 is prevalent among African-Americans: implications for pharmacogenetic dosing. Pharmacogenomics. 2009 Aug;10(8):1243-55.

Thus, in this racial group, the incorporation of CYP2C9*8 into genotyping panels may improve dose prediction of CYP2C9-metabolized drugs, including warfarin.
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19031075 Lindh JD, Holm L, Andersson ML, Rane A: Influence of CYP2C9 genotype on warfarin dose requirements--a systematic review and meta-analysis. Eur J Clin Pharmacol. 2009 Apr;65(4):365-75. Epub 2008 Nov 25.

METHODS: A systematic review and a meta-analysis, calculating the warfarin dose reduction associated with the five most common variant CYP2C9 genotypes.
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19300499 Takeuchi F, McGinnis R, Bourgeois S, Barnes C, Eriksson N, Soranzo N, Whittaker P, Ranganath V, Kumanduri V, McLaren W, Holm L, Lindh J, Rane A, Wadelius M, Deloukas P: A genome-wide association study confirms VKORC1, CYP2C9, and CYP4F2 as principal genetic determinants of warfarin dose. PLoS Genet. 2009 Mar;5(3):e1000433. Epub 2009 Mar 20.

Prior work established that approximately 30% of the dose variance is explained by single nucleotide polymorphisms (SNPs) in the warfarin drug target VKORC1 and another approximately 12% by two non-synonymous SNPs (*2, *3) in the cytochrome P450 warfarin-metabolizing gene CYP2C9.
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18315785 Okada Y, Nakamura K, Adachi A, Watai Y, Horiuchi R, Yamamoto K: Development of a single-tube PCR-pyrosequencing method for the simultaneous and rapid detection of four variant alleles of CYP2C9 gene polymorphism. J Clin Pharm Ther. 2008 Apr;33(2):187-92.

BACKGROUND AND OBJECTIVE: CYP2C9 is a polymorphic enzyme that has been reported to metabolize several clinically useful drugs such as warfarin, phenytoin and non-steroidal anti-inflammatory drugs.
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18636784 Lee MH, Graham GG, Williams KM, Day RO: A benefit-risk assessment of benzbromarone in the treatment of gout. Drug Saf. 2008;31(8):643-65.

If all the reported cases are assumed to be due to benzbromarone, the estimated risk of hepatotoxicity in Europe was approximately 1 in 17 000 patients but may be higher in Japan.Benzbromarone is also an inhibitor of CYP2C9 and so may be involved in drug interactions with drugs dependent on this enzyme for clearance, such as warfarin.
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19233910 Rai AJ, Udar N, Saad R, Fleisher M: A multiplex assay for detecting genetic variations in CYP2C9, VKORC1, and GGCX involved in warfarin metabolism. Clin Chem. 2009 Apr;55(4):823-6. Epub 2009 Feb 20.

Genetic variations in the cytochrome P450, family 2, subfamily C, polypeptide 9 (CYP2C9), vitamin K epoxide reductase complex, subunit 1 (VKORC1), and gamma-glutamyl carboxylase (GGCX) genes have been shown to contribute to impaired metabolism of warfarin.
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19934397 Brantley SJ, Oberlies NH, Kroll DJ, Paine MF: Two flavonolignans from milk thistle (Silybum marianum) inhibit CYP2C9-mediated warfarin metabolism at clinically achievable concentrations. J Pharmacol Exp Ther. 2010 Mar;332(3):1081-7. Epub 2009 Nov 24.

Based on a recent clinical study showing an interaction between a silymarin product and the CYP2C9 substrate losartan, the CYP2C9 inhibition properties of silybin A and silybin B and corresponding regioisomers, isosilybin A and isosilybin B, were evaluated using human liver microsomes (HLMs), recombinant CYP2C9 (rCYP2C9) enzymes, and the clinically relevant probe, (S)-warfarin.
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20162308 Helsby NA, Lo WY, Thompson P, Laking GR: Do 5-fluorouracil therapies alter CYP2C19 metaboliser status? . Cancer Chemother Pharmacol. 2010 Feb 17.

Down regulation of CYP2C9 and CYP2C19 synthesis by 5FU therapies may explain the adverse effect of 5FU on the clinical disposition of warfarin and phenytoin.
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20171411 Spangler ML, Saxena S: Warfarin and bosentan interaction in a patient with pulmonary hypertension secondary to bilateral pulmonary emboli. Clin Ther. 2010 Jan;32(1):53-6.

CONCLUSIONS: Bosentan has CYP3A4- and CYP2C9-inducing properties and is therefore likely to cause decreased concentrations of warfarin.
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19245785 DiMaio Knych HK, DeStefano Shields C, Buckpitt AR, Stanley SD: Equine cytochrome P450 2C92: cDNA cloning, expression and initial characterization. Arch Biochem Biophys. 2009 May 1;485(1):49-55. Epub 2009 Feb 24.

CYP2C92 demonstrated comparable tolbutamide and (S)-warfarin hydroxylase activity compared to CYP2C9, upon addition of b (5) to the reactions.
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19538716 Branco CC, Pereirinha T, Cabral R, Pacheco PR, Mota-Vieira L: Thrombotic genetic risk factors and warfarin pharmacogenetic variants in Sao Miguel's healthy population (Azores). Thromb J. 2009 Jun 18;7:9.

We also analysed the CYP2C9 (C430T, A1075C) and VKORC1 (G1639A) variants in fifty-eight individuals with predisposition to thrombosis (possessing at least one variation in F5 or F2 genes and one in MTHFR) to evaluate their warfarin drug response genetic profiles.
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19397481 Lippi G, Franchini M, Favaloro EJ: Pharmacogenetics of vitamin K antagonists: useful or hype? . Clin Chem Lab Med. 2009;47(5):503-15.

Growing evidence indicates that up to 60% of the individual pharmacological response to coumarins might be due to genetic variables and affected by polymorphisms in the genes encoding two enzymes, namely, vitamin K epoxide reductase (VKOR) and cytochrome P450 CYP2C9.
Genetic testing has been proposed as a useful tool for allowing prediction of the dose response during initial anticoagulation therapy, to assess variability in dose maintenance and to identify warfarin 'resistance'.
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18563532 Cavallari LH, Aston JL, Momary KM, Shapiro NL, Patel SR, Nutescu EA: Predictors of unstable anticoagulation in African Americans. J Thromb Thrombolysis. 2009 May;27(4):430-7. Epub 2008 Jun 19.

PATIENTS AND METHODS: Sixty African Americans on warfarin were enrolled.
Cytochrome P450 2C9 and vitamin K epoxide reductase genotypes and vitamin K intake were assessed, and clinical and dietary data during the 12 months prior to enrollment were collected.
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19955245 Moyer TP, O'Kane DJ, Baudhuin LM, Wiley CL, Fortini A, Fisher PK, Dupras DM, Chaudhry R, Thapa P, Zinsmeister AR, Heit JA: Warfarin sensitivity genotyping: a review of the literature and summary of patient experience. Mayo Clin Proc. 2009 Dec;84(12):1079-94.

For the 189 Mayo Clinic patients initiating warfarin therapy to achieve a target international normalized ratio (INR) in the range of 2.0 to 3.5, we analyzed the CYP2C9 (cytochrome P450 2C9) and VKORC1 (vitamin K epoxide reductase complex, subunit 1) genetic loci to study the relationship among the initial warfarin dose, steady-state dose, time to achieve steady-state dose, variations in INR, and allelic variance.
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19941044 Yuen E, Gueorguieva I, Wise S, Soon D, Aarons L: Ethnic differences in the population pharmacokinetics and pharmacodynamics of warfarin. J Pharmacokinet Pharmacodyn. 2010 Feb;37(1):3-24. Epub 2009 Nov 26.

The presence of a single *2 or *3 CYP2C9 allele reduced mean [SE (standard error)] S-warfarin clearance by 35% from 0.276 (0.04) to 0.180 (0.11) l/h.
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19139476 Gulseth MP, Grice GR, Dager WE: Pharmacogenomics of warfarin: uncovering a piece of the warfarin mystery. Am J Health Syst Pharm. 2009 Jan 15;66(2):123-33.

Cytochrome P-450 isoenzyme 2C9 (CYP2C9) metabolizes S-warfarin into two inactive metabolites.
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20339978 Ozer N, Cam N, Tangurek B, Ozer S, Uyarel H, Oz D, Guney MR, Ciloglu F: The impact of CYP2C9 and VKORC1 genetic polymorphism and patient characteristics upon warfarin dose requirements in an adult Turkish population. Heart Vessels. 2010 Mar;25(2):155-62. Epub 2010 Mar 26.
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19845677 Choppin A, Irwin I, Lach L, McDonald MG, Rettie AE, Shao L, Becker C, Palme MP, Paliard X, Bowersox S, Dennis DM, Druzgala P: Effect of tecarfarin, a novel vitamin K epoxide reductase inhibitor, on coagulation in beagle dogs. Br J Pharmacol. 2009 Nov;158(6):1536-47. Epub 2009 Oct 20.

Consistent with the inhibitory effects of amiodarone on CYP2C9, co-administration of amiodarone significantly increased the anticoagulation effect of warfarin and plasma warfarin concentrations.
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19479657 Cavallari LH, Limdi NA: Warfarin pharmacogenomics. Curr Opin Mol Ther. 2009 Jun;11(3):243-51.

The cytochrome P450 (CYP) 2C9 and vitamin K epoxide reductase complex 1 (VKORC1) genes have recently been determined to be associated with warfarin dose requirements, with reduced doses of this drug being required in patients with the variant CYP2C9*2, CYP2C9*3, or VKORC1 -1639A allele.
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19177029 Huang SW, Chen HS, Wang XQ, Huang L, Xu DL, Hu XJ, Huang ZH, He Y, Chen KM, Xiang DK, Zou XM, Li Q, Ma LQ, Wang HF, Chen BL, Li L, Jia YK, Xu XM: Validation of VKORC1 and CYP2C9 genotypes on interindividual warfarin maintenance dose: a prospective study in Chinese patients. Pharmacogenet Genomics. 2009 Mar;19(3):226-34.
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18763667 LaSala A, Bower B, Windemuth A, White CM, Kocherla M, Seip R, Duconge J, Ruano G: Integrating genomic based information into clinical warfarin (Coumadin) management: an illustrative case report. Conn Med. 2008 Aug;72(7):399-403.

The combination of physiologic factors (30%), CYP2C9 variations (20%) and VKORC1 variants (25%) accounts for approximately 75% of warfarin dose variability.
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18535201 Cooper GM, Johnson JA, Langaee TY, Feng H, Stanaway IB, Schwarz UI, Ritchie MD, Stein CM, Roden DM, Smith JD, Veenstra DL, Rettie AE, Rieder MJ: A genome-wide scan for common genetic variants with a large influence on warfarin maintenance dose. Blood. 2008 Aug 15;112(4):1022-7. Epub 2008 Jun 5.

Warfarin dosing is correlated with polymorphisms in vitamin K epoxide reductase complex 1 (VKORC1) and the cytochrome P450 2C9 (CYP2C9) genes.
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19408964 Miller GP, Jones DR, Sullivan SZ, Mazur A, Owen SN, Mitchell NC, Radominska-Pandya A, Moran JH: Assessing cytochrome P450 and UDP-glucuronosyltransferase contributions to warfarin metabolism in humans. Chem Res Toxicol. 2009 Jul;22(7):1239-45.

On the basis of total OH-WAR levels, (S)-7-OH-WAR was the predominant metabolite indicating the significance of CYP2C9 in WAR metabolism, although other CYP2C enzymes also contributed to clearance of this isomer. (R)-WAR hydroxylation to OH-WARs was more diverse among the patients as reflected in varying contributions of CYP1A2 and multiple CYP2C enzymes.
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18758764 Becquemont L: Evidence for a pharmacogenetic adapted dose of oral anticoagulant in routine medical practice. Eur J Clin Pharmacol. 2008 Oct;64(10):953-60. Epub 2008 Aug 30.

Carriers of cytochrome P450 2C9 (CYP2C9)-deficient alleles have a reduced clearance of warfarin and are exposed to dramatic overdoses in the first weeks of treatment.
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18374198 Siguret V, Pautas E, Gouin-Thibault I: Warfarin therapy: influence of pharmacogenetic and environmental factors on the anticoagulant response to warfarin. Vitam Horm. 2008;78:247-64.

SNPs of cytochrome P450 2C9 (CYP2C9) gene have been shown to decrease the catabolism of warfarin.
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18606741 Tai G, Dickmann LJ, Matovic N, DeVoss JJ, Gillam EM, Rettie AE: Re-engineering of CYP2C9 to probe acid-base substrate selectivity. Drug Metab Dispos. 2008 Oct;36(10):1992-7. Epub 2008 Jul 7.

We expressed and purified the R108E and R108E/D293N mutants and compared their ability with that of native CYP2C9 to interact with (S)-warfarin, diclofenac, pyrene, propranolol, and ibuprofen amine.
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18776969 Sinxadi P, Blockman M: Warfarin resistance. Cardiovasc J Afr. 2008 Jul-Aug;19(4):215-7.

Genetic polymorphism of the VKORC1 and CYP2C9 genes, as well as clinical factors such as age, gender, body mass index and interacting drugs explain less than 55% of variability in warfarin dose requirements.
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18542936 Oner Ozgon G, Langaee TY, Feng H, Buyru N, Ulutin T, Hatemi AC, Siva A, Saip S, Johnson JA: VKORC1 and CYP2C9 polymorphisms are associated with warfarin dose requirements in Turkish patients. Eur J Clin Pharmacol. 2008 Sep;64(9):889-94. Epub 2008 Jun 10.
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18679669 Almeida L, Falcao A, Vaz-da-Silva M, Nunes T, Santos AT, Rocha JF, Neta C, Macedo T, Fontes-Ribeiro C, Soares-da-Silva P: Effect of nebicapone on the pharmacokinetics and pharmacodynamics of warfarin in healthy subjects. Eur J Clin Pharmacol. 2008 Oct;64(10):961-6. Epub 2008 Aug 6.

In vitro, nebicapone has showed an inhibitory effect upon CYP2C9, which is responsible for the metabolism of S-warfarin.
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18252229 Scott SA, Edelmann L, Kornreich R, Desnick RJ: Warfarin pharmacogenetics: CYP2C9 and VKORC1 genotypes predict different sensitivity and resistance frequencies in the Ashkenazi and Sephardi Jewish populations. Am J Hum Genet. 2008 Feb;82(2):495-500. Epub 2008 Jan 17.
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19135231 Yoshizawa M, Hayashi H, Tashiro Y, Sakawa S, Moriwaki H, Akimoto T, Doi O, Kimura M, Kawarasaki Y, Inoue K, Itoh K: Effect of VKORC1-1639 G> A polymorphism, body weight, age, and serum albumin alterations on warfarin response in Japanese patients. Thromb Res. 2009 Jun;124(2):161-6. Epub 2009 Jan 9.

INTRODUCTION: To establish individualized warfarin therapy, we investigated the contribution of genetic variations of vitamin K epoxide reductase complex subunit 1 gene (VKORC1) -1639 G> A and Cytochrome P450 2C9 gene (CYP2C9) and clinical factors on warfarin sensitivity in Japanese patients.
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18836275 Yildirim H, Tamer L, Sucu N, Atik U: The role of CYP2C9 gene polymorphisms on anticoagulant therapy after heart valve replacement. Med Princ Pract. 2008;17(6):464-7. Epub 2008 Oct 3.

OBJECTIVE: The aim of the present study was to investigate the role of CYP2C9 gene polymorphisms after heart valve replacement in a group of patients on warfarin therapy.
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20101557 Rosskopf D, Meyer zu Schwabedissen HE, Kroemer HK, Siegmund W: [Pharmacogenomics in routine medical care] . Dtsch Med Wochenschr. 2010 Jan;135(4):133-44; quiz 145-6. Epub 2010 Jan 25.


Examples include genotyping of CYP2D6 in the context of antidepressant therapy, analysis of TPMT variants for the prediction of mercaptopurine-induced bone marrow depression, VKORC1 and CYP2C9 analyses for a better control of anticoagulant administration and the SLCO1B1 variant in the context of statin-induced myopathies.
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18464049 Au N, Rettie AE: Pharmacogenomics of 4-hydroxycoumarin anticoagulants. Drug Metab Rev. 2008;40(2):355-75.

Oral anticoagulants of the 4-hydroxycoumarin class, typified by warfarin, are used worldwide to treat thromboembolic disease.
Our understanding of the latter complication has improved significantly in recent years due to intense investigation of genetic factors influencing drug pharmacokinetics (CYP2C9) and pharmacodynamic response (VKORC1).
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19067473 Vakily M, Lee RD, Wu J, Gunawardhana L, Mulford D: Drug interaction studies with dexlansoprazole modified release (TAK-390MR), a proton pump inhibitor with a dual delayed-release formulation: results of four randomized, double-blind, crossover, placebo-controlled, single-centre studies. Clin Drug Investig. 2009;29(1):35-50. doi: 10.2165/0044011-200929010-00004.

Based on in vitro studies, dexlansoprazole has the potential to inhibit activity of these isoenzymes and also may induce human hepatic CYP1A and CYP2C9 activity.
METHODS: Four separate randomized, double-blind, two-way crossover, placebo-controlled, single-centre studies were conducted in healthy volunteers to evaluate the effect of dexlansoprazole on the pharmacokinetics of four test substrates (diazepam, phenytoin, theophylline [administered as intravenous aminophylline] and warfarin), which were selected based on in vitro and/or in vivo data that suggest a potential drug interaction with CYP isoenzymes or potentially coadministered narrow therapeutic index drugs.
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18784266 Inoue T, Nitta K, Sugihara K, Horie T, Kitamura S, Ohta S: CYP2C9-catalyzed metabolism of S-warfarin to 7-hydroxywarfarin in vivo and in vitro in chimeric mice with humanized liver. Drug Metab Dispos. 2008 Dec;36(12):2429-33. Epub 2008 Sep 10.
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19258521 Mosher CM, Tai G, Rettie AE: CYP2C9 amino acid residues influencing phenytoin turnover and metabolite regio- and stereochemistry. J Pharmacol Exp Ther. 2009 Jun;329(3):938-44. Epub 2009 Mar 3.

This pattern of effects differs substantially from that found previously for (S)-warfarin and (S)-flurbiprofen metabolism, suggesting that these three ligands bind within discrete locations in the CYP2C9 active site.
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19652664 Kaur-Knudsen D, Bojesen SE, Nordestgaard BG: Common polymorphisms in CYP2C9, subclinical atherosclerosis and risk of ischemic vascular disease in 52,000 individuals. Pharmacogenomics J. 2009 Oct;9(5):327-32. Epub 2009 Aug 4.

Cytochrome P450 2C9 (CYP2C9) enzymes metabolize warfarin and arachidonic acid.
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19297519 McDonald MG, Rieder MJ, Nakano M, Hsia CK, Rettie AE: CYP4F2 is a vitamin K1 oxidase: An explanation for altered warfarin dose in carriers of the V433M variant. Mol Pharmacol. 2009 Jun;75(6):1337-46. Epub 2009 Mar 18.

Genetic polymorphisms in VKORC1 and CYP2C9, genes controlling vitamin K (1) (VK1) epoxide reduction and (S)-warfarin metabolism, respectively, are major contributors to interindividual variability in warfarin dose.
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19074093 Francis CW: New issues in oral anticoagulants. Hematology Am Soc Hematol Educ Program. 2008:259-65.

Polymorphisms in CYP2C9, a critical cytochrome P-450 enzyme in the metabolism of warfarin, alters its clearance and affects dosing.
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19354002 Gallelli L, Ferraro M, Spagnuolo V, Rende P, Mauro GF, De Sarro G: Rosuvastatin-induced rhabdomyolysis probably via CYP2C9 saturation. Drug Metabol Drug Interact. 2009;24(1):83-7.

Our patient was taking rosuvastatin, warfarin and telmisartan, which are metabolised by CYP2C9; we therefore hypothesised that the rosuvastatin-induced rhabdomyolysis was probably by CYP2C9 enzyme saturation.
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20350128 Manolopoulos VG, Ragia G, Tavridou A: Pharmacogenetics of coumarinic oral anticoagulants. Pharmacogenomics. 2010 Apr;11(4):493-6.

Several retrospective and a few small prospective clinical studies have shown that polymorphisms in CYP2C9 and VKORC1 genes together account for 35-50% of the variability in warfarin initiation and maintenance dose requirements.
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20220045 Kirby LC, Johnson BM, Adams LM, Eberwein DJ, Zhang K, Murray SC, Lates CD, Blum RA, Morris SR: Effect of Casopitant, a Novel NK-1 Receptor Antagonist, on the Pharmacokinetics and Pharmacodynamics of Steady-State Warfarin. J Clin Pharmacol. 2010 Mar 10.

Casopitant, a novel NK-1 receptor antagonist under investigation for the prevention of postoperative and chemotherapy-induced nausea and vomiting, is a weak to moderate inhibitor of CYP3A and a moderate inducer of CYP2C9 in vitro.
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18838506 Hutzler JM, Balogh LM, Zientek M, Kumar V, Tracy TS: Mechanism-based inactivation of cytochrome P450 2C9 by tienilic acid and (+/-)-suprofen: a comparison of kinetics and probe substrate selection. Drug Metab Dispos. 2009 Jan;37(1):59-65. Epub 2008 Oct 6.

In vitro experiments were conducted to compare k (inact), K (I) and inactivation efficiency (k (inact)/K (I)) of cytochrome P450 (P450) 2C9 by tienilic acid and (+/-)-suprofen using (S)-flurbiprofen, diclofenac, and (S)-warfarin as reporter substrates.
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