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Biohellenika

Backround :

The oral treatment with antivitamin K is being applied in clinical practice almost exclusively for the prevention and treatment of thromboembolic disease. This treatment often comes with haemorrhagic or thrombotic complications that are connected with the right adjustment of the dosage and the follow up of the treatment due to number of factors that are involved such as age, body weight, nutrition habits and genetic factors.

The oral anticoagulant treatment (with Warfarin, Acenocoumarol, Ρhenprocoumon Fluindione), is responsible for the 10% of all side effects connected with drugs and lead to emergency hospitalisation.

The causes of these hospitalizations are attributed to minor or major hemorrhagic manifestations (about 1% of the cases appear with major complications), and at the same time as failures in the right adjustment of the oral anticoagulation treatment, that often comes up with recurrent thrombotic events.

Bodin et al, Blood 2005

For this failure various acquired or hereditary factors have been implicated

We have problems with adjusting the treatment due to the fact that in some patients an augmented resistance was observed. This resistance is connected with the mutation of the vitamin K epoxidase (VKORC1),

In the same time some patients were observed with augmented sensitivity for which a number of polymorphisms were implicated.

Liver dysfunction Metabolic syndromes

Vitamin K epoxide reductase complex subunit 1 (VKORC1)

Various responses in the Warfarin dose between the patients

frequency

sensitivity CYP2C9 coding SNPs - *3/*3

Common VKORC1 non-coding SNPs?

resistance VKORC1 nonsynonymous coding SNPs

0.5 5 15 Conservative dose of Warfarin (mg/day)

n = 222

Πολυμορφισμός 1639 G>A
1 oral dose of Sintrom 37% decrease of F7 30% change in INR

Bodin, et al. Blood 2005

Warfarin resistance (dose >20 mg /d with sub-therapeutic INR) non associable patient lab mistakes excess of vit- K (oral or parenteric) mutations in the reductated vitamin K epoxidase (rare) Rost et al., Nature 2004; 427: 537 Warfarin sensitivity (dose <2 mg /D with sub-therapeutic INR) Cytochrome P450 polymorphism (acts in the rate of metabolism)
28 mononucleotidic polymorphisms of VKORC1. Also the 1639 G>A polymorphism is related with increased sensitivity

It has been observed that the haemorrhagic problems appear much more often. When the research for the genetic causes that affect the adjustment of the antivitamin K treatment took place the polymorphism VKORC1 1173 C>T and mainly the homozygote form (1173TT) was found to be connected with frequent haemorrhagic complications due to the fact that the homozygotes have increased sensitivity in low doses of antivitamin K.

On the contrary the patients with 1173CC form require at least the double dosage of antivitamin K to reach the wanted results (INR=2.5)

The detection of this mutation between greek patients receiving oral anticoagulant treatment.

We studied 184 subjects, from which 49 were normal (28 male, 21 female) the control group with out receiving any anticoagulant and (Χ=33±15 years old) and 135 thrombophilic patients (71 male, 64 female). in oral anticoagulant treatment with antivitamin K. (Χ=45 ± 17 years old)

Methods: DNA extraction with the Qiagen kit, we applied conventional PCR technology with TIB MOLBIOL scheduled primers and the products were digested with Hinf 1 restriction enzyme from Roche Molecular Biochemicals. The digestion products were studied with electrophoresis in agarose 2% gell.

From the 49 normal subjects we found out that 27 of them were heterozygote, 12 homozygote CC and 10 homozygote TT (fig). From the 135 thrombophilic patients we found 28 homozygote TT (who were treated with 2.5±0.69 mg of antivitamin K daily), 71 heterozygote CT (who were treated with 3.5±0.9 mg daily), and 36 homozygote CC (who were treated with 4.25±0.9 mg daily).

We found out that indeed the homozyte TT needed a smaller dosage of antivitamin K in comparison with the heterozygote CT and the CC homozygote. We note that our patients did not show any haemorrhagic or thrombotic complications It is true that this mutation was detected for first time in Greece