Genotype-guided versus traditional clinical dosing of warfarin in patients of Asian ancestry: A randomized controlled trial

Abstract

Background: Genotype-guided warfarin dosing has been shown in some randomized trials to improve anticoagulation outcomes in individuals of European ancestry, yet its utility in Asian patients remains unresolved. Methods: An open-label, non-inferiority, 1:1 randomized trial was conducted at three academic hospitals in South East Asia, involving 322 ethnically diverse patients newly indicated for warfarin (NCT00700895). Clinical follow-up was 90days. The primary efficacy measure was the number of dose titrations within the first 2weeks of therapy, with a mean non-inferiority margin of 0.5 over the first 14days of therapy. Results: Among 322 randomized patients, 269 were evaluable for the primary endpoint. Compared with traditional dosing, the genotype-guided group required fewer dose titrations during the first 2weeks (1.77 vs. 2.93, difference -1.16, 90% CI -1.48 to -0.84, P<0.001 for both non-inferiority and superiority). The percentage of time within the therapeutic range over 3months and median time to stable international normalized ratio (INR) did not differ between the genotype-guided and traditional dosing groups. The frequency of dose titrations (incidence rate ratio 0.76, 95% CI 0.67 to 0.86, P=0.001), but not frequency of INR measurements, was lower at 1, 2, and 3months in the genotype-guided group. The proportions of patients who experienced minor or major bleeding, recurrent venous thromboembolism, or out-of-range INR did not differ between both arms. For predicting maintenance doses, the pharmacogenetic algorithm achieved an R 2=42.4% (P<0.001) and mean percentage error of -7.4%. Conclusions: Among Asian adults commencing warfarin therapy, a pharmacogenetic algorithm meets criteria for both non-inferiority and superiority in reducing dose titrations compared with a traditional dosing approach, and performs well in prediction of actual maintenance doses. These findings imply that clinicians may consider applying a pharmacogenetic algorithm to personalize initial warfarin dosages in Asian patients.