J Clin Outcomes Manage
Periprocedural anticoagulation management in orthopedic patients: overview and description of a program utilizing pharmacogenetics
Grice GR, Laramie D, Anderson DC Jr
Abstract Objective: To review current recommendations for periprocedural anticoagulation management strategies in orthopedic patients and to describe a program utilizing pharmacogenetics in warfarin management of orthopedic surgical patients. Methods: Review of the literature and descriptive report. Results: A large body of evidence supports the use of anticoagulation in surgical patients, and strategies for optimizing its use have been developed. Genetic markers, including single nucleotide polymorphisms (SNPs) found in cytochrome P450-2C9 (CYP2C9) and vitamin K 2,3-epoxide reductase complex 1 (VKORC1), have been identified that aid in the management of warfarin, a drug with a narrow therapeutic index complicated by the wide variability in dose–response. Several algorithms incorporating genetics have been published that demonstrate the potential for these models to predict warfarin doses. In our orthopedic patients (n > 1000), we have found a high correlation between actual therapeutic dose and pharmacogenetic-predicted dose (56%) as well as pharmacogenetic-refined dose (79%) and have demonstrated decreased adverse effects of supratherapeutic international normalized ratios and major bleeding. Conclusion: The optimal method for periprocedural management of orthopedic surgical patients will depend on an institution’s policies and procedures as well as patient and clinician preferences. If warfarin is chosen for anticoagulation and an institution has the ability to genotype patients, the option to use patient-specific genetic information in addition to a variety of important patient-specific clinical information is available and has shown promising results for improved patient outcomes. A randomized trial is needed to determine the exact role of pharmacogenetics in patient management.
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