A rolling-horizon pharmacokinetic pharmacodynamic model for warfarin inpatients in transient clinical states
Abstract
Aim: To design a pharmacokinetic pharmacodynamic model to make individualized and adaptive international normalized ratio (INR) predictions for warfarin inpatients in changing clinical status. Methods: We tested a new model on 60 inpatients at Columbia University. The model personalizes four submodels and minimizes the number of parameters to be estimated. Prediction accuracy was assessed by prediction error, absolute prediction error and percentage absolute prediction error. Results: The INRs were accurately predicted 5 days into the future. Median prediction error: 0.01–0.12; median absolute prediction error: 0.17–0.5 and median percentage absolute prediction error: 9.85–26.06%. Conclusion: Patients exhibit interindividual and intertemporal variability. The model captures the variability and provides accurate and personalized INR predictions.
Papers of special note have been highlighted as: • of interest; •• of considerable interest
References
- 1 . Atrial fibrillation through the years: contemporary evaluation and management. Circulation 127(3), 408–416 (2013). • Provides a comprehensive review of the advancements in clinical evaluation, treatment and management of atrial fibrillation.
- 2 Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Aassociation. Stroke 45(7), 2160–2236 (2014). • Provides evidence-based guidelines for anticoagualtion and stroke prevention for clinical practitioners.
- 3 . Non-vitamin K antagonist oral anticoagulants in cardiovascular disease management: evidence and unanswered questions. J. Clin. Pharm. Ther. 39(2), 118–135 (2014).
- 4 Overanticoagulation associated with combined use of antibacterial drugs and acenocoumarol or phenprocoumon anticoagulants. Thromb. Haemost. 88(5), 705–710 (2002).
- 5 Proton pump inhibitors and the risk of overanticoagulation during acenocoumarol maintenance treatment. Br. J. Haematol. 153(3), 379–385 (2011).
- 6 Potential interaction between acenocoumarol and diclofenac, naproxen and ibuprofen and role of CYP2C9 genotype. Thromb. Haemost. 91(1), 95–101 (2004).
- 7 . The influence of cyclo-oxygenase specificity of non-steroidal anti-inflammatory drugs on bleeding complications in concomitant coumarine users. QJM 96(7), 513–520 (2003).
- 8 . Warfarin and antiplatelet combination use among commercially insured patients enrolled in an anticoagulation management service. Chest 131(5), 1500–1507 (2007).
- 9 . Outcomes associated with combined antiplatelet and anticoagulant therapy. Chest 133(4), 948–954 (2008).
- 10 Association of pharmacokinetic (CYP2C9) and pharmacodynamic (factors II, VII, IX, and X; proteins S and C; and gamma-glutamyl carboxylase) gene variants with warfarin sensitivity. Blood 103(7), 2630–2635 (2004).
- 11 A polymorphism in the VKORC1 gene is associated with an interindividual variability in the dose-anticoagulant effect of warfarin. Blood 105(2), 645–649 (2005).
- 12 The impact of CYP2C9 and VKORC1 genetic polymorphism and patient characteristics upon warfarin dose requirements: proposal for a new dosing regimen. Blood 106(7), 2329–2333 (2005).
- 13 Genetic determinants of response to warfarin during initial anticoagulation. N. Engl. J. Med. 358(10), 999–1008 (2008).
- 14 Different contributions of polymorphisms in VKORC1 and CYP2C9 to intra- and inter-population differences in maintenance dose of warfarin in Japanese, Caucasians and African–Americans. Pharmacogenet. Genomics 16(2), 101–110 (2006).
- 15 A genome-wide scan for common genetic variants with a large influence on warfarin maintenance dose. Blood 112(4), 1022–1027 (2008).
- 16 The largest prospective warfarin-treated cohort supports genetic forecasting. Blood 113(4), 784–792 (2009).
- 17 . Warfarin and its interactions with foods, herbs and other dietary supplements. Expert Opin. Drug Saf. 5(3), 433–451 (2006).
- 18 . Vitamin K supplementation to decrease variability of international normalized ratio in patients on vitamin K antagonists: A literature review. Curr. Opin. Hematol. 15(5), 504–508 (2008).
- 19 Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2), e152S–e184S (2012).
- 20 . Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action. Arch. Intern. Med. 167(13), 1414–1419 (2007).
- 21 . Optimal level of oral anticoagulant therapy for the prevention of arterial thrombosis in patients with mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction: a prospective study of 4202 patients. Arch. Intern. Med. 169(13), 1203–1209 (2009).
- 22 . Management and dosing of warfarin therapy. Am. J. Med. 109(6), 481–488 (2000).
- 23 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and The Heart Rhythm Society. J. Am. Coll. Cardiol. 60, 1740–1749 (2014).
- 24 Twelve-month outcomes and predictors of very stable INR control in prevalent warfarin users. J. Thromb. Haemost. 8(4), 744–749 (2010).
- 25 . Anticoagulation control in the peri-hospitalization period. J. Gen. Intern. Med. 22(6), 727–735 (2007).
- 26 Outcomes and predictors of very stable INR control during chronic anticoagulation therapy. Blood 114(5), 952–956 (2009).
- 27 The influence of patient adherence on anticoagulation control with warfarin: results from the international normalized ratio Adherence and Genetics (IN-RANGE) Study. Arch. Intern. Med. 167(3), 229–235 (2007).
- 28 Can we predict daily adherence to warfarin? Results from the international normalized ratio Adherence and Genetics (IN-RANGE) Study. Chest 137(4), 883–889 (2010).
- 29 . Warfarin dose management affects INR control. J. Thromb. Haemost. 7(1), 94–101 (2009).
- 30 . Patient characteristics associated with oral anticoagulation control: results of the Veterans AffaiRs Study to Improve Anticoagulation (VARIA). J. Thromb. Haemost. 8(10), 2182–2191 (2010).
- 31 Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest. 133(6), 160S–198S (2008).
- 32 . Improving the quality of anticoagulation of patients with atrial fibrillation in managed care organizations: results of the managing anticoagulation services trial. Am. J. Med. 113(1), 42–45 (2002). • Provides practical evidence on the effectiveness of the warfarin dosing protocols and methods currently used in practice.
- 33 . Efficacy of computer-aided dosing of warfarin among patients in a rehabilitation hospital. Am. J. Phys. Med. Rehabil. 84(6), 423–427 (2005).
- 34 . A computer generated induction system for hospitalized patients starting on oral anticoagulant therapy. Thromb. Haemost. 83(6), 849–852 (2000).
- 35 Variation in warfarin dose adjustment practice is responsible for differences in the quality of anticoagulation control between centers and countries: an analysis of patients receiving warfarin in the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial. Circulation 126, 2309–2316 (2012).
- 36 . Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvar atrial fibrillation: a record linkage study in a large British population. Heart 91(4), 472–477 (2005).
- 37 Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Lancet 376(9745), 975–983 (2010).
- 38 . Individualizing warfarin therapy. Pers. Med. 4, 11–31 (2007). • Provides evidence that multiple regression models with genetic information and combinations of patient's physical attributes can better explain warfarin dose variability than models with only genetic information.
- 39 . Understanding the dose–effect relationship: clinical application of pharmacokinetic-pharmacodynamic models. Clin. Pharmacokinet. 6(6), 429–453 (1981). • The first paper to study the dose–effect relationship between warfarin and international normalized ratio (INR) from a pharmacokinetic pharmacodynamic (PK/PD) perspective.
- 40 . Clinical pharmacokinetics and pharmacodynamics of warfarin. Understanding the dose–effect relationship. Clin. Pharmacokinet. 11(6), 483–504 (1986). •• The first paper to define the four submodels for the clinical PK and PD of warfarin; it also proposes various mathematical equations suitable for each of the submodels.
- 41 . Development of a Bayesian forecasting method for warfarin dose individualization. Pharm. Res. 28(5), 1100–1111 (2011). • Reviews and compares existing PK/PD models for warfarin and INR, and proposes a Bayesian forecasting method for INR and warfarin doses.
- 42 . A model-based algorithm for the monitoring of long-term anticoagulation therapy. J. Thromb. Haemost. 3(5), 915–921 (2005). • Simplifies the model by [44] for the long-term anticoagulation treatment of outpatients with visit intervals between 1 and 6 weeks.
- 43 . Prediction of the international normalized ratio and maintenance dose during the initiation of warfarin therapy. Br. J. Clin. Pharmacol. 48, 63–70 (1999). • Provides a PK/PD model, which can accurately predict the INR and maintenance dose during the initiation of warfarin therapy.
- 44 . Evaluation of three dosage-prediction methods for initial in-hospital stabilization of warfarin therapy. Clin. Pharm. 6(1), 37–45 (1987).
- 45 Initiation of warfarin therapy – comparison of physician dosing with computer-assisted dosing. J. Gen. Intern. Med. 3, 141–148 (1987).
- 46 . A Bayesian dose-individualization method for warfarin. Clin. Pharmacokinet. 52(1), 59–68 (2013). • Assesses the predictive performance of the Bayesian method by [45] on 55 warfarin patients and finds that the method can accurately predict the steady-state INR.
- 47 . Outpatient management of warfarin therapy: comparison of computer-predicted dosage adjustment to skilled professional care. Ther. Drug Monit. 13(1), 46–50 (1991).
- 48 A pharmacometic model describing the relationship between warfarin dose and INR response with respect to variations in CYP2C9, VKORC1, and age. Clin. Pharmacol. Ther. 87(6), 727–734 (2010). • Develops a population PK/PD model that describes the relationship between warfarin dose and INR response and also takes into account genetic variations.
- 49 . Nested partitions method for global optimization. Oper. Res. 48(3), 390–407 (2000).
- 50 . Nested Partitions Method, Theory and Applications. Springer Science + Business Media, NY, USA (2009).
- 51 . Some suggestions for measuring predictive performance. J. Pharmacokinet. Biopharm. 9(4), 503–512 (1981).