Influence of adult age on the total and free clearance and protein binding of (R)- and (S)-warfarin

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To test the hypothesis that the clearance (CL) of warfarin, a very highly protein bound drug with capacity-limited metabolism, decreases with age.


In a clinical study, a steady-state blood sample was taken from 72 patients (18–89 years) on routine treatment with warfarin. Concentrations of (R)- and (S)-warfarin were determined in plasma (total) and ultrafiltrate (free) by LC-MS/MS. Total and free CL and protein binding were determined and regressed against age and other covariates. In an ex vivo study, warfarin was spiked to plasma samples from 60 healthy subjects (19–87 years) and protein binding was regressed against age and other covariates.


For (R)-warfarin a significant decrease with age was found for both total and free CL (P < 0.001). For (S)-warfarin there was a stronger signal of a decrease with age in free CL (P= 0.005) vs. total CL (P= 0.045). The decrease in CL of (R)- and (S)-warfarin was 0.3–0.5% per year. Other covariates influencing CL were lean body weight for both (R)- and (S)-warfarin and CYP2C9 genotype and blood sampling time for (S)-warfarin. Protein binding of (R)- and (S)-warfarin was not found to change significantly with age in either the clinical or the spiked samples, despite a slight decrease in albumin concentration with age.


These data support the hypothesis that the CL of (R)- and (S)-warfarin decreases with age. More accurate information was gained when measuring free CL for (S)-warfarin. Warfarin protein binding did not change significantly with age.

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