BIOTRANSFORMATION OF

DRUGS

Warfarin
Coumadin® the most common
anticoagulant drug

By
ALAGAR . S
M.Tech/Computational Biology
Background
 In the early 20th century, bis-hydroxycoumarin
(dicumarol) was discovered after cows livestock
had eaten spoiled Sweet clover and died of a
hemorrhagic disease.
 Today, coumarin derivatives are used
therapeutically as anticoagulants and commercially
as rodenticides. Warfarin is the most common oral
anticoagulant used today.
 Approximately 2 million people in the U.S. start
taking warfarin each year.
What is Warfarin?
 Warfarin is an oral coumarin anticoagulant widely
used to control and prevent thromboembolic
disorders.
 Warfarin is clinically available as a racemic mixture
of R- and S-warfarin. The S-enantiomer has 3–5
times greater anticoagulation potency than its
optical congener R-warfarin.
Mechanism of Action
 Warfarin acts by antagonizing the antihemorrhagic
effect of vitamin K.
 It inhibits hepatic synthesis of vitamin K dependent
coagulation factors II, VII, IX, and X by inhibiting
vitamin K1 -2,3 epoxide reductase, preventing
vitamin K from being reduced to its active form.
 Vitamin K is an essential cofactor for post-
translational carboxylation of glutamate
residues on the N-terminus regions of vitamin
K-dependent proteins to gamma-carboxy-
glutamates
Mechanism of Action
Decarboxyprothrombin is converted to prothrombin by
carboxylation of glutamate residues to gamma-
carboxyglutamate
By inhibiting vitamin K epoxide reductase and vitamin K –
reductase, warfarin leads to the accumulation of vitamin K
epoxide in the liver and plasma and the depletion of reduced
vitamin K (active form, KH2)
Reduced vitamin K is necessary for carboxylation of –
glutamate residues
Decrease in KH2 limits the gamma-carboxylation of vitamin K –
dependent coagulant proteins -
Factors VII, IX, X Prothrombin (Factor II) –
Protein C and Protein S
 Factor II Carboxylated
(10 glutamic Factor II
residues) CO2 COO-
C H 2 -C H 2 C O O - Pro t ei n CH2-CH
carb oxyl ase
COO-

O2
OH O
R R

CH3 CH3
Reduced O Epoxide form
Vitamin K OH Wafarin Vitamin K
Vitamin K
(active) r e d u c t a se blocks (inactive)

blocked by Vitamin K
Warfarin epoxide
reductase
T hi o l
Cof act or
Pharmacokinetic
 The oral bioavailability of warfarin is nearly 100%.
 It is highly bound (approximately 99%) to plasma
protein, mainly albumin. (The high degree of protein binding is
one of several mechanisms whereby other drugs interact with warfarin)

 Warfarin is distributed to the liver, lungs, spleen,

and kidneys. It does not appear to be distributed to
breast milk in significant amounts. It crosses the
placenta and is a known teratogen.
 The duration of anticoagulant effect after a single
dose of warfarin is usually 5-7 days.
Pharmacokinetic (cont’d)
 Warfarin is metabolized by hepatic cytochrome
P-450 (CYP) isoenzymes to inactive metabolites,
which are excreted in the bile. (It also is metabolized by
reductases to reduced metabolites “warfarin alcohols” , which are excreted in
the kidneys).

 Warfarin metabolism may be altered in the

presence of hepatic dysfunction or advanced age
but is not affected by renal impairment.
Warfarin Monitoring
 Prothrombin time (PT) — The most commonly used
test to measure the effect of warfarin. It measures
the time it takes for the clotting mechanism to
progress. Normal range (12–15 seconds).
 International Normalized Ratio (INR) — The INR is a way
of expressing the PT in a standardized way; this ensures that results obtained
by different laboratories can be reliably compared.

• The longer it takes the blood to clot, the higher the

PT and INR. In most cases the target INR range
will be 2 to 3, although other ranges may be chosen
if there are special circumstances.
PHASE-1 METABOLISM
PHASE-1 METABOLISM
 PHASE-1 METABOLISM
. Kinetic profiles for the formation of each product of the reactions are as
follows: squares () for 6-hydroxywarfarin, triangles (▴) for 7-
hydroxywarfarin, inverted triangles (▾) for 8-hydroxywarfarin, and
diamonds (◆) for 4′-hydroxywarfarin. Reported values represent
three experiments performed in duplicate. Data were fit to the
Michaelis-Menten mechanism using GraphPad Prism 5® software
(La Jolla, CA)
 PHASE-2 METABOLISM

Glucuronidation of Warfarin Metabolites

PHASE-2 METABOLISM
Excretion of metabolites through Bile(P-
Glycoprotein transporters) and urine
TOXICITY
 Hemorrhaging
 Warfarin induced skin necrosis
 Drug interactions
 Teratogen in pregnant women

OVER DOSE TREATMENT

 Stop taking warfarin

 Vitamin K1 treatment in excess dose
 Fresh frozen plasma with vitaminK1
References
 Katzung PHARMACOLOGY, 9e > Drugs Used in
Disorders of Coagulation
 emedicine.medscape.com>Toxicity, Warfarin and
Superwarfarins, Warfarin Pharmacogenetics.
 drugs.com/pro/warfarin
 uptodate.com>Patient information: Warfarin
 Drug Metab Lett. 2012 September 1; 6(3): 157–164
 The journal of pharmacology and experimental
therauputics Vol. 324, No. 1 129858/3285451
JPET 324:139–148, 2008