• Mark H Eckman, Jonathan Rosand, Steven M Greenberg, and Brian F Gage.
• University of Cincinnati Medical Center, Cincinnati, OH 45267-0535, USA. mark.eckman@uc.edu
• Ann. Intern. Med. 2009 Jan 20; 150 (2): 738373-83.

BackgroundVariants in genes involved in warfarin metabolism and sensitivity affect individual warfarin requirements and the risk for bleeding. Testing for these variant alleles might allow more personalized dosing of warfarin during the induction phase. In 2007, the U.S. Food and Drug Administration changed the labeling for warfarin (Coumadin, Bristol-Myers Squibb, Princeton, New Jersey), suggesting that clinicians consider genetic testing before initiating therapy.ObjectiveTo examine the cost-effectiveness of genotype-guided dosing versus standard induction of warfarin therapy for patients with nonvalvular atrial fibrillation.DesignMarkov state transition decision model.Data SourcesMEDLINE searches and bibliographies from relevant articles of literature published in English.Target PopulationOutpatients or inpatients requiring initiation of warfarin therapy. The base case was a man age 69 years with newly diagnosed nonvalvular atrial fibrillation and no contraindications to warfarin therapy.Time HorizonLifetime.PerspectiveSocietal.InterventionGenotype-guided dosing consisting of genotyping for CYP2C9*2, CYP2C9*3, and/or VKORC1 versus standard warfarin induction.Outcome MeasuresEffectiveness was measured in quality-adjusted life-years (QALYs), and costs were in 2007 U.S. dollars.ResultsIn the base case, genotype-guided dosing resulted in better outcomes, but at a relatively high cost. Overall, the marginal cost-effectiveness of testing exceeded $170 000 per QALY. On the basis of current data and cost of testing (about $400), there is only a 10% chance that genotype-guided dosing is likely to be cost-effective (that is, <$50 000 per QALY). Sensitivity analyses revealed that for genetic testing to cost less than $50 000 per QALY, it would have to be restricted to patients at high risk for hemorrhage or meet the following optimistic criteria: prevent greater than 32% of major bleeding events, be available within 24 hours, and cost less than $200.LimitationFew published studies describe the effect of genotype-guided dosing on major bleeding events, and although these studies show a trend toward decreased bleeding, the results are not statistically significant.ConclusionWarfarin-related genotyping is unlikely to be cost-effective for typical patients with nonvalvular atrial fibrillation, but may be cost-effective in patients at high risk for hemorrhage who are starting warfarin therapy.

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