Economic evaluation of pharmacogenomic-guided warfarin treatment for elderly Croatian atrial fibrillation patients with ischemic stroke

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From: Pharmacogenomics(Vol. 16, Issue 2)
Publisher: Future Medicine Ltd.
Document Type: Report
Length: 6,435 words
Lexile Measure: 1600L

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Author(s): Christina Mitropoulou aff1 , Vasilios Fragoulakis aff2 aff3 , Nada Bozina aff4 aff5 , Athanassios Vozikis aff6 , Svjetlana Supe aff7 , Tamara Bozina aff8 , Zdravka Poljakovic aff7 , Ron H van Schaik aff1 , George P Patrinos [*] aff2


atrial fibrillation; cost-effectiveness analysis; ischemic stroke; pharmacogenomics economic evaluation; warfarin

Atrial fibrillation (AF) is the commonest cardiac arrhythmia of the general population. The prevalence of AF increases with age from [less than] 0.5% at those of 40-50 years to 5-15% at those at 80 years of age, while, due to demographic trends, its frequency is expected to rise in the future [ 1-8 ]. As a result, AF represents a significant public health problem, as it has been associated with increased rates of stroke, systemic embolism, heart failure and left ventricular dysfunction, which in turn result in reduced quality of life and higher death rates [7,9-12 ]. Moreover, AF also generates significant healthcare services utilization and represents a great economic burden for the modern healthcare systems [ 13-24 ]. Anticoagulant therapy with warfarin decreases the risk of embolic stroke by 50%; however warfarin poses a risk for major hemorrhagic events such as intracranial hemorrhage and gastrointestinal bleeding [25,26 ].

Warfarin dose requirement depends on several demographic and nutritional factors, as well as the medical history of the patient, while it also has a strong genetic component with main role of CYP2C9 and VKORC1 genotypes. In particular, carriers of CYP2C9 genomic variants metabolize S-warfarin more slowly than patients bearing the wild-type allele, leading to elevated international normalized ratios (INRs) at common initial doses of warfarin [27 ], while carriers of VKORC1 genomic variants require a lower warfarin dose as well, to appropriately inhibit coagulation. Obviously, variations in both genomic loci induce resistance to warfarin [27 ]. CYP2C9 and VKORC1 polymorphisms account for up to 18 and 30%, respectively, of the variance in stable warfarin dose among patients of European ancestry, and genotyping of these variants has the potential to improve clinical management of warfarin treatment and reciprocally decrease the likelihood of bleeding [28 ]. In this case, however, CYP2C9 and VKORC1 pharmacogenomic (PGx) testing represents an additional cost item, which efficacy and economic outcomes still remains unknown for the majority of healthcare systems.

In Croatia, like in many developing countries, health resources are scarce and demographic and technological trends are pushing budgets upwards. Therefore, it is important to find ways that can aid decision makers to direct resources to the most efficient therapies. This is even more important in the context of the present global financial crisis and the pressures upon public budgets. Hence, to guide efficient resource allocation, an economic evaluation was undertaken in order to assess the therapeutic alternatives available for thrombophylaxis in the management of AF in elderly patients in Croatia who developed ischemic stroke. It must be noted that several cost-effectiveness studies have been conducted in general comparing PGx-guided warfarin treatment but this is the first one conducted in the local setting in extremely vulnerable patients.

The aim of the present study was to conduct an...

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Gale Document Number: GALE|A413526801