"May 23, 2012 -- Aspirin may be effective long-term to reduce the risk of repeat blood clots in veins, new research suggests.
Patients who have these potentially dangerous blood clots, called venous thromboembolism or VTE, often get th"...
Mechanism of Action
Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX, and X, and the anticoagulant proteins C and S. Vitamin K is an essential cofactor for the post ribosomal synthesis of the vitamin K-dependent clotting factors. Vitamin K promotes the biosynthesis of γ-carboxyglutamic acid residues in the proteins that are essential for biological activity. Warfarin is thought to interfere with clotting factor synthesis by inhibition of the C1 subunit of vitamin K epoxide reductase (VKORC1) enzyme complex, thereby reducing the regeneration of vitamin K1 epoxide.
An anticoagulation effect generally occurs within 24 hours after warfarin administration. However, peak anticoagulant effect may be delayed 72 to 96 hours. The duration of action of a single dose of racemic warfarin is 2 to 5 days. The effects of COUMADIN may become more pronounced as effects of daily maintenance doses overlap. This is consistent with the half-lives of the affected vitamin K-dependent clotting factors and anticoagulation proteins: Factor II - 60 hours, VII - 4 to 6 hours, IX - 24 hours, X - 48 to 72 hours, and proteins C and S are approximately 8 hours and 30 hours, respectively.
COUMADIN is a racemic mixture of the R- and S-enantiomers of warfarin. The S-enantiomer exhibits 2 to 5 times more anticoagulant activity than the R-enantiomer in humans, but generally has a more rapid clearance.
Warfarin is essentially completely absorbed after oral administration, with peak concentration generally attained within the first 4 hours.
Warfarin distributes into a relatively small apparent volume of distribution of about 0.14 L/kg. A distribution phase lasting 6 to 12 hours is distinguishable after rapid intravenous or oral administration of an aqueous solution. Approximately 99% of the drug is bound to plasma proteins.
The elimination of warfarin is almost entirely by metabolism. Warfarin is stereo-selectively metabolized by hepatic cytochrome P-450 (CYP450) microsomal enzymes to inactive hydroxylated metabolites (predominant route) and by reductases to reduced metabolites (warfarin alcohols) with minimal anticoagulant activity. Identified metabolites of warfarin include dehydrowarfarin, two diastereoisomer alcohols, and 4'-, 6-, 7-, 8-, and 10-hydroxywarfarin. The CYP450 isozymes involved in the metabolism of warfarin include CYP2C9, 2C19, 2C8, 2C18, 1A2, and 3A4. CYP2C9, a polymorphic enzyme, is likely to be the principal form of human liver CYP450 that modulates the in vivo anticoagulant activity of warfarin. Patients with one or more variant CYP2C9 alleles have decreased S-warfarin clearance.
The terminal half-life of warfarin after a single dose is approximately 1 week; however, the effective half-life ranges from 20 to 60 hours, with a mean of about 40 hours. The clearance of R-warfarin is generally half that of S-warfarin, thus as the volumes of distribution are similar, the half-life of R-warfarin is longer than that of S-warfarin. The half-life of R-warfarin ranges from 37 to 89 hours, while that of S-warfarin ranges from 21 to 43 hours. Studies with radiolabeled drug have demonstrated that up to 92% of the orally administered dose is recovered in urine. Very little warfarin is excreted unchanged in urine. Urinary excretion is in the form of metabolites.
Patients 60 years or older appear to exhibit greater than expected INR response to the anticoagulant effects of warfarin. The cause of the increased sensitivity to the anticoagulant effects of warfarin in this age group is unknown but may be due to a combination of pharmacokinetic and pharmacodynamic factors. Limited information suggests there is no difference in the clearance of S-warfarin; however, there may be a slight decrease in the clearance of R-warfarin in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of warfarin is usually required to produce a therapeutic level of anticoagulation [see DOSAGE AND ADMINISTRATION].
Asian patients may require lower initiation and maintenance doses of warfarin. A non-controlled study of 151 Chinese outpatients stabilized on warfarin for various indications reported a mean daily warfarin requirement of 3.3 ± 1.4 mg to achieve an INR of 2 to 2.5. Patient age was the most important determinant of warfarin requirement in these patients, with a progressively lower warfarin requirement with increasing age.
CYP2C9 and VKORC1 Polymorphisms
The S-enantiomer of warfarin is mainly metabolized to 7-hydroxywarfarin by CYP2C9, a polymorphic enzyme. The variant alleles, CYP2C9*2 and CYP2C9*3, result in decreased in vitro CYP2C9 enzymatic 7-hydroxylation of S-warfarin. The frequencies of these alleles in Caucasians are approximately 11% and 7% for CYP2C9*2 and CYP2C9*3, respectively.
Other CYP2C9 alleles associated with reduced enzymatic activity occur at lower frequencies, including *5, *6, and *11 alleles in populations of African ancestry and *5, *9, and *11 alleles in Caucasians.
Warfarin reduces the regeneration of vitamin K from vitamin K epoxide in the vitamin K cycle through inhibition of VKOR, a multiprotein enzyme complex. Certain single nucleotide polymorphisms in the VKORC1 gene (e.g., –1639G > A) have been associated with variable warfarin dose requirements. VKORC1 and CYP2C9 gene variants generally explain the largest proportion of known variability in warfarin dose requirements.
CYP2C9 and VKORC1 genotype information, when available, can assist in selection of the initial dose of warfarin [see DOSAGE AND ADMINISTRATION].
In five prospective, randomized, controlled clinical trials involving 3711 patients with non-rheumatic AF, warfarin significantly reduced the risk of systemic thromboembolism including stroke (see Table 4). The risk reduction ranged from 60% to 86% in all except one trial (CAFA: 45%), which was stopped early due to published positive results from two of these trials. The incidence of major bleeding in these trials ranged from 0.6% to 2.7% (see Table 4).
Table 4: Clinical Studies of Warfarin in Non-Rheumatic AF Patients*
|Study||N||Thromboembolism||% Major Bleeding|
|Warfarin- Treated Patients||Control Patients||PT Ratio||INR||% Risk Reduction||p-value||Warfarin- Treated Patients||Control Patients|
|* All study results of warfarin vs. control are based on intention-to-treat analysis and include ischemic stroke and systemic thromboembolism, excluding hemorrhagic stroke and transient ischemic attacks.|
Trials in patients with both AF and mitral stenosis suggest a benefit from anticoagulation with COUMADIN [see DOSAGE AND ADMINISTRATION].
Mechanical and Bioprosthetic Heart Valves
In a prospective, randomized, open-label, positive-controlled study in 254 patients with mechanical prosthetic heart valves, the thromboembolic-free interval was found to be significantly greater in patients treated with warfarin alone compared with dipyridamole/aspirin-treated patients (p < 0.005) and pentoxifylline/aspirin-treated patients (p < 0.05). The results of this study are presented in Table 5.
Table 5: Prospective,
Randomized, Open-Label, Positive-Controlled Clinical Study of Warfarin in
Patients with Mechanical Prosthetic Heart Valves
|Event||Patients Treated With|
|Warfarin||Dipyridamole/ Aspirin||Pentoxifylline/ Aspirin|
|Thromboembolism||2.2/100 py||8.6/100 py||7.9/100 py|
|Major Bleeding||2.5/100 py||0.0/100 py||0.9/100 py|
In a prospective, open-label, clinical study comparing moderate (INR 2.65) vs. high intensity (INR 9.0) warfarin therapies in 258 patients with mechanical prosthetic heart valves, thromboembolism occurred with similar frequency in the two groups (4.0 and 3.7 events per 100 patient years, respectively). Major bleeding was more common in the high intensity group. The results of this study are presented in Table 6.
Table 6: Prospective,
Open-Label Clinical Study of Warfarin in Patients with Mechanical Prosthetic
|Event||Moderate Warfarin Therapy INR 2.65||High Intensity Warfarin Therapy INR 9.0|
|Thromboembolism||4.0/100 py||3.7/100 py|
|Major Bleeding||0.95/100 py||2.1/100 py|
In a randomized trial in 210 patients comparing two intensities of warfarin therapy (INR 2.0-2.25 vs. INR 2.5-4.0) for a three-month period following tissue heart valve replacement, thromboembolism occurred with similar frequency in the two groups (major embolic events 2.0% vs. 1.9%, respectively, and minor embolic events 10.8% vs. 10.2%, respectively). Major hemorrhages occurred in 4.6% of patients in the higher intensity INR group compared to zero in the lower intensity INR group.
WARIS (The Warfarin Re-Infarction Study) was a double-blind, randomized study of 1214 patients 2 to 4 weeks post-infarction treated with warfarin to a target INR of 2.8 to 4.8. The primary endpoint was a composite of total mortality and recurrent infarction. A secondary endpoint of cerebrovascular events was assessed. Mean follow-up of the patients was 37 months. The results for each endpoint separately, including an analysis of vascular death, are provided in Table 7.
Table 7: WARIS – Endpoint
Analysis of Separate Events
|RR (95% CI)||% Risk Reduction (p-value)|
|Total Patient Years of Follow-up||2018||1944|
|Total Mortality Vascular Death||94 (4.7/100 py) 82 (4.1/100 py)||123 (6.3/100 py) 105 (5.4/100 py)||0.76 (0.60, 0.97) 0.78 (0.60, 1.02)||24 (p=0.030) 22 (p=0.068)|
|Recurrent MI||82 (4.1/100 py)||124 (6.4/100 py)||0.66 (0.51, 0.85)||34 (p=0.001)|
|Cerebrovascular Event||20 (1.0/100 py)||44 (2.3/100 py)||0.46 (0.28, 0.75)||54 (p=0.002)|
|RR=Relative risk; Risk reduction=(1 - RR); CI=Confidence interval; MI=Myocardial infarction; py=patient years|
WARIS II (The Warfarin, Aspirin, Re-Infarction Study) was an open-label, randomized study of 3630 patients hospitalized for acute myocardial infarction treated with warfarin to a target INR 2.8 to 4.2, aspirin 160 mg per day, or warfarin to a target INR 2.0 to 2.5 plus aspirin 75 mg per day prior to hospital discharge. The primary endpoint was a composite of death, nonfatal reinfarction, or thromboembolic stroke. The mean duration of observation was approximately 4 years. The results for WARIS II are provided in Table 8.
Table 8: WARIS II –
Distribution of Events According to Treatment Group
|Aspirin plus Warfarin
|Rate Ratio (95% CI)||p-value|
|No. of Events|
|Major Bleedinga||8||33||28||3.35b (ND) 4.00c (ND)||ND ND|
|Minor Bleedingd||39||103||133||3.21b (ND) 2.55c (ND)||ND ND|
|Composite Endpointse||241||203||181||0.81 (0.69-0.95)b 0.71 (0.60-0.83)c||0.03 0.001|
|Reinfarction||117||90||69||0.56 (0.41-0.78)b 0.74 (0.55-0.98)c||< 0.001 0.03|
|Thromboembolic Stroke||32||17||17||0.52 (0.28-0.98)b 0.52 (0.28-0.97)c||0.03 0.03|
|a Major bleeding episodes were defined as nonfatal cerebral hemorrhage or bleeding necessitating surgical intervention or blood
bThe rate ratio is for aspirin plus warfarin as compared with aspirin.
c The rate ratio is for warfarin as compared with aspirin.
d Minor bleeding episodes were defined as non-cerebral hemorrhage not necessitating surgical intervention or blood transfusion.
eIncludes death, nonfatal reinfarction, and thromboembolic cerebral stroke.
There were approximately four times as many major bleeding episodes in the two groups receiving warfarin than in the group receiving aspirin alone. Major bleeding episodes were not more frequent among patients receiving aspirin plus warfarin than among those receiving warfarin alone, but the incidence of minor bleeding episodes was higher in the combined therapy group.
Last reviewed on RxList: 10/2/2012
This monograph has been modified to include the generic and brand name in many instances.
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