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Genotype-guided versus standard vitamin K antagonist dosing algorithms in patients initiating anticoagulation. A systematic review and meta-analysis.
Thromb Haemost. 2015 Jul 9;114(3)
Authors: Belley-Cote EP, Hanif H, D'Aragon F, Eikelboom JW, Anderson JL, Borgman M, Jonas DE, Kimmel SE, Manolopoulos VG, Baranova E, Maitland-van der Zee AH, Pirmohamed M, Whitlock RP
Abstract
Variability in vitamin K antagonist (VKA) dosing is partially explained by genetic polymorphisms. We performed a meta-analysis to determine whether genotype-guided VKA dosing algorithms decrease a composite of death, thromboembolic events and major bleeding (primary outcome) and improve time in therapeutic range (TTR). We searched MEDLINE, EMBASE, CENTRAL, trial registries and conference proceedings for randomised trials comparing genotype-guided and standard (non genotype-guided) VKA dosing algorithms in adults initiating anticoagulation. Data were pooled using a random effects model. Of the 12 included studies (3,217 patients), six reported all components of the primary outcome of mortality, thromboembolic events and major bleeding (2,223 patients, 87 events). Our meta-analysis found no significant difference between groups for the primary outcome (relative risk 0.85, 95 % confidence interval [CI] 0.54-1.34; heterogeneity Χ²=4.46, p=0.35, I²=10 %). Based on 10 studies (2,767 patients), TTR was significantly higher in the genotype-guided group (mean difference (MD) 4.31 %; 95 % CI 0.35, 8.26; heterogeneity Χ²=43.31, p< 0.001, I²=79 %). Pre-specified exploratory analyses demonstrated that TTR was significantly higher when genotype-guided dosing was compared with fixed VKA dosing (6 trials, 997 patients: MD 8.41 %; 95 % CI 3.50,13.31; heterogeneity Χ²=15.18, p=0.01, I²=67 %) but not when compared with clinical algorithm-guided dosing (4 trials, 1,770 patients: MD -0.29 %; 95 % CI -2.48,1.90; heterogeneity Χ²=1.53, p=0.68, I²=0 %; p for interaction=0.002). In conclusion, genotype-guided compared with standard VKA dosing algorithms were not found to decrease a composite of death, thromboembolism and major bleeding, but did result in improved TTR. An improvement in TTR was observed in comparison with fixed VKA dosing algorithms, but not with clinical algorithms.
PMID: 26158747 [PubMed - as supplied by publisher]