A varfarina é o anticoagulante oral mais prescrito no mundo todo. Algoritmos farmacogenéticos têm sido desenvolvidos para estimar a dose de varfarina. Os principais objetivos deste estudo foram desenvolver um algoritmo farmacogenético estimador de dose de varfarina e comparar o algoritmo desenvolvido neste trabalho com algoritmos disponíveis na literatura. Para atingir os objetivos foram incluídos dois grupos de pacientes tratados com varfarina (primeira coorte, n = 832; e segunda coorte, n = 133). Foram realizadas as genotipagens dos polimorfismos CYP2C9*2, CYP2C9*3 e VKORC1 (c.G1639A). A derivação do algoritmo foi realizada utilizando os dados dos pacientes da primeira coorte com dose estável (n=368) e foi replicado utilizando os dados dos pacientes provenientes da segunda coorte (n=133). Como resultado o algoritmo desenvolvido neste trabalho alcançou um coeficiente de determinação de 40%, incluindo as variáveis: idade, sexo, peso, altura, raça autodeclarada, uso de amiodarona, uso de indutores enzimáticos, os genótipos na VKORC1 (c.G1639A) e os fenótipos de acordo com polimorfismos CYP2C9. Os dados sugerem que o nosso algoritmo desenvolvido é mais acurado do que o algoritmo IWPC (The International Warfarin Pharmacogenetics Consortium) quando a aplicação é focada em pacientes brasileiros. Os algoritmos farmacogenéticos estimadores de dose de varfarina desenvolvidos para uma população específica podem ser mais efetivos para a terapia com varfarina em comparação com o uso de algoritmos estimadores de dose atualmente disponíveis / Warfarin is the most prescribed oral anticoagulant in the world. Pharmacogenetic algorithms have been developed to estimate the dose of warfarin. The main aims of the present study were to develop a pharmacogenetic-based warfarin dosing algorithm and compare algorithm developed in this study with others algorithms available in the literature. We included two patient cohorts treated with warfarin (first cohort, n = 832; and second cohort, n = 133). Polymorphisms were genotyped in the CYP2C9 * 2, CYP2C9 * 3 and VKORC1 (c.G1639A). The derivation of the algorithm was performed using the data from the patients in the first cohort with a stable dose (n = 368) and was replicated using data from patients from the second cohort (n = 133). Our algorithm achieved a determination of coefficient of 40%, including variables: age, sex, weight, height, self-declared race, use of amiodarone, use of enzymatic inducers, genotypes in VKORC1 (c.G1639A) and phenotypes according to CYP2C9 polymorphisms. Our data suggest that the developed algorithm is more accurate than the IWPC algorithm when the application is focused on patients from the Brazilian population. Pharmacogenetics- based warfarin dosing algorithms developed for a specific population may lead to improved performance compared use dosing algorithms currently available

INTRODUCTION Des réponses thérapeutiques variables aux glucocorticoïdes (GCs) sont observées parmi les patients atteints de la leucémie lymphoblastique aiguë (LLA). Les protéines Bax et Bim ont déjà montré un rôle important dans l’apoptose des cellules leucémiques. L’expression de Bax était plus basse chez les patients leucémiques résistants au médicament, de même une sensibilité diminuée aux GCs a été associée avec une expression réduite de Bim. La différence dans l’expression pourrait être due à des polymorphismes présents dans ces gènes et donc être associés avec la résistance aux GCs. MÉTHODE Dix-huit polymorphismes en régions régulatrices, 2 polymorphismes exoniques et 7 polymorphismes en région 3’UTR de ces gènes ont été analysés chez les témoins (n=50) et ont permis de déterminer un nombre minimal de polymorphismes suffisants pour définir les haplotypes (tagSNPs). Ces 8 polymorphismes ont ensuite été génotypés chez 286 enfants atteints de la LLA et ont été testés pour l’issue de la maladie par l’analyse de survie. RÉSULTATS Une survie sans évènement et une survie sans rechute diminuées ont été observées pour l’haplotype 3 (p=0,03 et p=0,02). Une survie globale diminuée a été associée avec l’homozygotie pour l’allèle exonique T298C>T (p=0,03), de même que pour les haplotypes 1 et 4 (p=0,04 et p=0,02) du gène Bim. CONCLUSION Les polymorphismes ont été associés avec une survie diminuée chez des enfants atteints de LLA. Il reste à tester d’autres polymorphismes présents dans ces deux gènes ainsi qu’à définir leurs fonctions afin de comprendre leurs rôles dans la réponse aux GCs. / INTRODUCTION Variable therapeutic responses to glucocorticoids (GCs) are observed for acute lymphoblastic leukemia (ALL) patients. Proteins Bax and Bim have already shown to play a major role in mediating GC-induced apoptosis in leukemia cells. Bax expression was lower in drug-resistant leukemia samples; likewise lower sensitivity to GC was associated with reduced Bim expression. The difference in the expression can be due to polymorphisms in these genes and therefore associated to GC resistance. METHOD Eighteen polymorphisms in the regulatory region, two exonic polymorphisms and seven polymorphisms in 3’UTR of these genes were analysed in controls (n=50) and have permitted to determine a minimal number of polymorphisms sufficient to define haplotypes (tagSNPs). These 8 single nucleotide polymorphisms (SNPs) were then genotyped in 286 LLA children and were tested for disease outcome by survival analysis. RESULTS A diminished event free survival and a diminished relapse free survival were observed for haplotype 3 (p=0,03 and p=0,02). A diminished overall survival was associated with the exonic T298C>T allele (p=0,03) and with haplotypes 1 and 4 (p=004 and p=0,02) of Bim gene. CONCLUSION Bax and Bim were associated with a diminished survival in LLA children. We still have to test other polymorphisms located in these genes and to define their functions in order to understand their roles in GC response.

A varfarina é o anticoagulante oral mais prescrito no mundo todo. Algoritmos farmacogenéticos têm sido desenvolvidos para estimar a dose de varfarina. Os principais objetivos deste estudo foram desenvolver um algoritmo farmacogenético estimador de dose de varfarina e comparar o algoritmo desenvolvido neste trabalho com algoritmos disponíveis na literatura. Para atingir os objetivos foram incluídos dois grupos de pacientes tratados com varfarina (primeira coorte, n = 832; e segunda coorte, n = 133). Foram realizadas as genotipagens dos polimorfismos CYP2C9*2, CYP2C9*3 e VKORC1 (c.G1639A). A derivação do algoritmo foi realizada utilizando os dados dos pacientes da primeira coorte com dose estável (n=368) e foi replicado utilizando os dados dos pacientes provenientes da segunda coorte (n=133). Como resultado o algoritmo desenvolvido neste trabalho alcançou um coeficiente de determinação de 40%, incluindo as variáveis: idade, sexo, peso, altura, raça autodeclarada, uso de amiodarona, uso de indutores enzimáticos, os genótipos na VKORC1 (c.G1639A) e os fenótipos de acordo com polimorfismos CYP2C9. Os dados sugerem que o nosso algoritmo desenvolvido é mais acurado do que o algoritmo IWPC (The International Warfarin Pharmacogenetics Consortium) quando a aplicação é focada em pacientes brasileiros. Os algoritmos farmacogenéticos estimadores de dose de varfarina desenvolvidos para uma população específica podem ser mais efetivos para a terapia com varfarina em comparação com o uso de algoritmos estimadores de dose atualmente disponíveis / Warfarin is the most prescribed oral anticoagulant in the world. Pharmacogenetic algorithms have been developed to estimate the dose of warfarin. The main aims of the present study were to develop a pharmacogenetic-based warfarin dosing algorithm and compare algorithm developed in this study with others algorithms available in the literature. We included two patient cohorts treated with warfarin (first cohort, n = 832; and second cohort, n = 133). Polymorphisms were genotyped in the CYP2C9 * 2, CYP2C9 * 3 and VKORC1 (c.G1639A). The derivation of the algorithm was performed using the data from the patients in the first cohort with a stable dose (n = 368) and was replicated using data from patients from the second cohort (n = 133). Our algorithm achieved a determination of coefficient of 40%, including variables: age, sex, weight, height, self-declared race, use of amiodarone, use of enzymatic inducers, genotypes in VKORC1 (c.G1639A) and phenotypes according to CYP2C9 polymorphisms. Our data suggest that the developed algorithm is more accurate than the IWPC algorithm when the application is focused on patients from the Brazilian population. Pharmacogenetics- based warfarin dosing algorithms developed for a specific population may lead to improved performance compared use dosing algorithms currently available

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.