Biohellenika

Backround :

The oral treatment with antivitamin K is being applied in

clinical practice almost exclusively for the prevention and
treatment of thromboembolic disease.
This treatment often comes with haemorrhagic or
thrombotic complications that are connected with the right
adjustment of the dosage and the follow up of the
treatment due to number of factors that are involved such
as age, body weight, nutrition habits and genetic factors.
The oral anticoagulant treatment (with Warfarin,
Acenocoumarol, Ρhenprocoumon Fluindione), is
responsible for the 10% of all side effects connected
with drugs and lead to emergency hospitalisation.
The causes of these hospitalizations are attributed to
minor or major hemorrhagic manifestations (about 1%
of the cases appear with major complications), and at
the same time as failures in the right adjustment of the
oral anticoagulation treatment, that often comes up
with recurrent thrombotic events.

Bodin et al, Blood 2005

For this failure various acquired or
hereditary factors have been implicated
We have problems with adjusting the treatment due to the
fact that in some patients an augmented resistance was
observed. This resistance is connected with the mutation
of the vitamin K epoxidase (VKORC1),

In the same time some patients were observed with

augmented sensitivity for which a number of
polymorphisms were implicated.
„ Liver dysfunction
„ Metabolic syndromes
Vitamin K epoxide reductase complex subunit 1 (VKORC1)
 Various responses in the Warfarin dose between the patients
frequency

sensitivity resistance
VKORC1
CYP2C9 coding Common nonsynonymous
SNPs - *3/*3 VKORC1 coding
non-coding SNPs
SNPs?

0.5 5 15
Conservative dose of Warfarin (mg/day)
 n = 222

Πολυμορφισμός 1639 G>A

1 oral dose of Sintrom Bodin, et al. Blood 2005

37% decrease of F7
30% change in INR
Warfarin resistance (dose >20 mg /d with sub-therapeutic INR)
non associable patient
lab mistakes
excess of vit- K (oral or parenteric)
mutations in the reductated vitamin K epoxidase (rare)
Rost et al., Nature 2004; 427: 537
Warfarin sensitivity (dose <2 mg /D with sub-therapeutic INR)
Cytochrome P450 polymorphism
(acts in the rate of metabolism)
28 mononucleotidic polymorphisms of VKORC1.
Also the 1639 G>A polymorphism is related with increased sensitivity
It has been observed that the haemorrhagic problems
appear much more often. When the research for the
genetic causes that affect the adjustment of the
antivitamin K treatment took place the polymorphism
VKORC1 1173 C>T and mainly the homozygote form
(1173TT) was found to be connected with frequent
haemorrhagic complications due to the fact that the
homozygotes have increased sensitivity in low doses of
antivitamin K.
On the contrary the patients with 1173CC form require at least the double
dosage of antivitamin K to reach the wanted results (INR=2.5)

The detection of this mutation between greek patients

receiving oral anticoagulant treatment.
We studied 184 subjects, from which
49 were normal (28 male, 21 female) the control group
with out receiving any anticoagulant and
(Χ=33±15 years old) and
135 thrombophilic patients (71 male, 64 female).
in oral anticoagulant treatment with antivitamin K.
(Χ=45 ± 17 years old)
Methods:
DNA extraction with the Qiagen kit, we applied
conventional PCR technology with TIB MOLBIOL
scheduled primers and the products were digested with
Hinf 1 restriction enzyme from Roche Molecular
Biochemicals. The digestion products were studied with
electrophoresis in agarose 2% gell.
From the 49 normal subjects we found out that
27 of them were heterozygote,
12 homozygote CC and
10 homozygote TT (fig).

From the 135 thrombophilic patients we found

28 homozygote TT (who were treated with 2.5±0.69 mg of antivitamin K daily),
71 heterozygote CT (who were treated with 3.5±0.9 mg daily), and
36 homozygote CC (who were treated with 4.25±0.9 mg daily).
We found out that indeed the homozyte TT needed a
smaller dosage of antivitamin K in comparison with
the heterozygote CT and the CC homozygote.
We note that our patients did not show any
haemorrhagic or thrombotic complications
It is true that this mutation was detected for first time
in Greece