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Abstract
Pharmacogenetics is a key component of precision medicine. Genetic variation in drug metabolism enzymes can lead to variable exposure to drugs and metabolites, potentially leading to inefficacy and drug toxicity. Although the evidence for pharmacogenetic associations in children is not as extensive as for adults, there are several drugs across diverse therapeutic areas with robust pediatric data indicating important, and relatively common, drug-gene interactions. Guidelines to assist gene-based dose optimization are available for codeine, thiopurine drugs, selective serotonin reuptake inhibitors, atomoxetine, tacrolimus, and voriconazole. For each of these drugs, there is an opportunity to clinically implement precision medicine approaches with children for whom genetic test results are known or are obtained at the time of prescribing. For many more drugs that are commonly used in pediatric patients, additional investigation is needed to determine the genetic factors influencing appropriate dose.
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Affiliation(s)
- Laura B Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA
- Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
| | - Jacob T Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, Minnesota 55812, USA
| | - Susan I Vear
- Department of Hematology & Oncology, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, and Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA;
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52
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Massart MB. Genetic Disorders. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_16-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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53
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Nguyen KA, Patel H, Haggstrom DA, Zillich AJ, Imperiale TF, Russ AL. Utilizing a user-centered approach to develop and assess pharmacogenomic clinical decision support for thiopurine methyltransferase. BMC Med Inform Decis Mak 2019; 19:194. [PMID: 31623616 PMCID: PMC6798472 DOI: 10.1186/s12911-019-0919-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background A pharmacogenomic clinical decision support tool (PGx-CDS) for thiopurine medications can help physicians incorporate pharmacogenomic results into prescribing decisions by providing up-to-date, real-time decision support. However, the PGx-CDS user interface may introduce errors and promote alert fatigue. The objective of this study was to develop and evaluate a prototype of a PGx-CDS user interface for thiopurine medications with user-centered design methods. Methods This study had two phases: In phase I, we conducted qualitative interviews to assess providers’ information needs. Interview transcripts were analyzed through a combination of inductive and deductive qualitative analysis to develop design requirements for a PGx-CDS user interface. Using these requirements, we developed a user interface prototype and evaluated its usability (phase II). Results In total, 14 providers participated: 10 were interviewed in phase I, and seven providers completed usability testing in phase II (3 providers participated in both phases). Most (90%) participants were interested in PGx-CDS systems to help improve medication efficacy and patient safety. Interviews yielded 11 themes sorted into two main categories: 1) health care providers’ views on PGx-CDS and 2) important design features for PGx-CDS. We organized these findings into guidance for PGx-CDS content and display. Usability testing of the PGx-CDS prototype showed high provider satisfaction. Conclusion This is one of the first studies to utilize a user-centered design approach to develop and assess a PGx-CDS interface prototype for Thiopurine Methyltransferase (TPMT). This study provides guidance for the development of a PGx-CDS, and particularly for biomarkers such as TPMT.
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Affiliation(s)
- Khoa A Nguyen
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, 1225 Center Drive, Gainesville, FL, 32610, USA. .,Center for Health Services Research, Regenstrief Institute Inc., 1101 W 10th St, Indianapolis, IN, USA. .,Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN, 46202, USA. .,Department of Pharmacy Practice, College of Pharmacy, Purdue University, 640 Eskenazi Avenue, Indianapolis, IN, USA.
| | - Himalaya Patel
- Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN, 46202, USA
| | - David A Haggstrom
- Center for Health Services Research, Regenstrief Institute Inc., 1101 W 10th St, Indianapolis, IN, USA.,Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN, 46202, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alan J Zillich
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, 640 Eskenazi Avenue, Indianapolis, IN, USA
| | - Thomas F Imperiale
- Center for Health Services Research, Regenstrief Institute Inc., 1101 W 10th St, Indianapolis, IN, USA.,Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN, 46202, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alissa L Russ
- Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN, 46202, USA.,Department of Pharmacy Practice, College of Pharmacy, Purdue University, 640 Eskenazi Avenue, Indianapolis, IN, USA
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54
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Haga SB. Pharmacogenomic Testing In Pediatrics: Navigating The Ethical, Social, And Legal Challenges. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:273-285. [PMID: 31686893 PMCID: PMC6800463 DOI: 10.2147/pgpm.s179172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/12/2019] [Indexed: 12/17/2022]
Abstract
For the past several years, the implementation of pharmacogenetic (PGx) testing has become widespread in several centers and clinical practice settings. PGx testing may be ordered at the point-of-care when treatment is needed or in advance of treatment for future use. The potential benefits of PGx testing are not limited to adult patients, as children are increasingly using medications more often and at earlier ages. This review provides some background on the use of PGx testing in children as well as mothers (prenatally and post-natally) and discusses the challenges, benefits, and the ethical, legal, and social implications of providing PGx testing to children.
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Affiliation(s)
- Susanne B Haga
- Department of Medicine, Division of General Internal Medicine, Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, 27708, USA
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55
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Roden DM, Van Driest SL, Wells QS, Mosley JD, Denny JC, Peterson JF. Opportunities and Challenges in Cardiovascular Pharmacogenomics: From Discovery to Implementation. Circ Res 2019; 122:1176-1190. [PMID: 29700066 DOI: 10.1161/circresaha.117.310965] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This review will provide an overview of the principles of pharmacogenomics from basic discovery to implementation, encompassing application of tools of contemporary genome science to the field (including areas of apparent divergence from disease-based genomics), a summary of lessons learned from the extensively studied drugs clopidogrel and warfarin, the current status of implementing pharmacogenetic testing in practice, the role of genomics and related tools in the drug development process, and a summary of future opportunities and challenges.
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Affiliation(s)
- Dan M Roden
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.) .,Department of Pharmacology (D.M.R., Q.S.W.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| | - Sara L Van Driest
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Pediatrics (S.L.V.D.), Vanderbilt University Medical Center, Nashville, TN
| | - Quinn S Wells
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Pharmacology (D.M.R., Q.S.W.)
| | - Jonathan D Mosley
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.)
| | - Joshua C Denny
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| | - Josh F Peterson
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
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56
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Czarnecki ML, Hainsworth K, Simpson PM, Arca MJ, Uhing MR, Zhang L, Grippe A, Varadarajan J, Rusy LM, Firary M, Weisman SJ. A Pilot Randomized Controlled Trial of Outcomes Associated with Parent-Nurse Controlled Analgesia vs. Continuous Opioid Infusion in the Neonatal Intensive Care Unit. Pain Manag Nurs 2019; 21:72-80. [PMID: 31494028 DOI: 10.1016/j.pmn.2019.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/15/2019] [Accepted: 08/03/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Prospectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population. DESIGN/METHODS A randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction. RESULTS The sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction. CONCLUSIONS PNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation. CLINICAL IMPLICATIONS Patients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement. STUDY TYPE Treatment study. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Michelle L Czarnecki
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Keri Hainsworth
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa M Simpson
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery, Section of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marjorie J Arca
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery, Section of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael R Uhing
- Department of Surgery, Section of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Neonatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liyun Zhang
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ann Grippe
- Neonatal Intensive Care Unit, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jaya Varadarajan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lynn M Rusy
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary Firary
- Department of Pharmacy, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Steven J Weisman
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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57
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Abstract
With rapid advances in genetics and genomics, the commercialization and access to new applications has become more widespread and omnipresent throughout biomedical research. Thus, increasingly, more patients will have personal genomic information they may share with primary care providers (PCPs) to better understand the clinical significance of the data. To be able to respond to patient inquiries about genomic data, variant interpretation, disease risk, and other issues, PCPs will need to be able to increase or refresh their awareness about genetics and genomics, and identify reliable resources to use or refer patients. While provider educational efforts have increased, with the rapid advances in the field, ongoing efforts will be needed to prepare PCPs to manage patient needs, integrate results into care, and refer as indicated.
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Affiliation(s)
- Susanne B Haga
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, 27708, USA.
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58
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Lee CR, Sriramoju VB, Cervantes A, Howell LA, Varunok N, Madan S, Hamrick K, Polasek MJ, Lee JA, Clarke M, Cicci JD, Weck KE, Stouffer GA. Clinical Outcomes and Sustainability of Using CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 11:e002069. [PMID: 29615454 DOI: 10.1161/circgen.117.002069] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/05/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND CYP2C19 loss-of-function (LOF) alleles impair clopidogrel effectiveness after percutaneous coronary intervention. The feasibility, sustainability, and clinical impact of using CYP2C19 genotype-guided dual antiplatelet therapy (DAPT) selection in practice remains unclear. METHODS A single-center observational study was conducted in 1193 patients who underwent percutaneous coronary intervention and received DAPT after implementation of an algorithm that recommends CYP2C19 testing in high-risk patients and alternative DAPT (prasugrel or ticagrelor) in LOF allele carriers. The frequency of genotype testing and alternative DAPT selection were the primary implementation end points. Risk of major adverse cardiovascular or cerebrovascular and clinically significant bleeding events over 12 months were compared across genotype and DAPT groups by proportional hazards regression. RESULTS CYP2C19 genotype was obtained in 868 (72.8%) patients. Alternative DAPT was prescribed in 186 (70.7%) LOF allele carriers. CYP2C19 testing (P<0.001) and alternative DAPT use in LOF allele carriers (P=0.001) varied over time. Risk for major adverse cardiovascular or cerebrovascular was significantly higher in LOF carriers prescribed clopidogrel versus alternative DAPT (adjusted hazard ratio, 4.65; 95% confidence interval, 2.22-10.0; P<0.001), whereas no significant difference was observed in those without a LOF allele (adjusted hazard ratio, 1.37; 95% confidence interval, 0.72-2.85; P=0.347). Bleeding event rates were similar across groups (log-rank P=0.816). CONCLUSIONS Implementing CYP2C19 genotype-guided DAPT is feasible and sustainable in a real-world setting but challenging to maintain at a consistently high level of fidelity. The higher risk of major adverse cardiovascular or cerebrovascular associated with clopidogrel use in CYP2C19 LOF allele carriers suggests that use of genotype-guided DAPT in practice may improve clinical outcomes.
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Affiliation(s)
- Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill.
| | - Vindhya B Sriramoju
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Alexandra Cervantes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Lucius A Howell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Nicholas Varunok
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Shivanshu Madan
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Kasey Hamrick
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Melissa J Polasek
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - John Andrew Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Megan Clarke
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Jonathan D Cicci
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - Karen E Weck
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
| | - George A Stouffer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (C.R.L., A.C., K.H., M.J.P., J.A.L.), UNC Center for Pharmacogenomics and Individualized Therapy (C.R.L., K.E.W.), UNC McAllister Heart Institute (C.R.L., G.A.S.), Division of Cardiology, UNC School of Medicine (V.B.S., L.A.H., N.V., S.M., G.A.S.), Department of Pharmacy, UNC HealthCare Medical Center (M.C., J.D.C.), and Department of Pathology and Laboratory Medicine, UNC School of Medicine (K.E.W.), University of North Carolina at Chapel Hill
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Hicks JK, Aquilante CL, Dunnenberger HM, Gammal RS, Funk RS, Aitken SL, Bright DR, Coons JC, Dotson KM, Elder CT, Groff LT, Lee JC. Precision Pharmacotherapy: Integrating Pharmacogenomics into Clinical Pharmacy Practice. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019; 2:303-313. [PMID: 32984775 DOI: 10.1002/jac5.1118] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Precision pharmacotherapy encompasses the use of therapeutic drug monitoring; evaluation of liver and renal function, genomics, and environmental and lifestyle exposures; and analysis of other unique patient or disease characteristics to guide drug selection and dosing. This paper articulates real-world clinical applications of precision pharmacotherapy, focusing exclusively on the emerging field of clinical pharmacogenomics. This field is evolving rapidly, and clinical pharmacists now play an invaluable role in the clinical implementation, education, and research applications of pharmacogenomics. This paper provides an overview of the evolution of pharmacogenomics in clinical pharmacy practice, together with recommendations on how the American College of Clinical Pharmacy (ACCP) can support the advancement of clinical pharmacogenomics implementation, education, and research. Commonalities among successful clinical pharmacogenomics implementation and education programs are identified, with recommendations for how ACCP can leverage and advance these common themes. Opportunities are also provided to support the research needed to move the practice and application of pharmacogenomics forward.
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Abstract
Pharmacogenomics, a key part of precision medicine, has the potential to tailor drug therapy with the high safety margins and optimized response. Before the Human Genome Project in 2003, articles on pharmacogenomics were limited. The last 15 years have seen significant growth in the field, with gene variant discoveries that play essential roles in individuals' drug response. Dermatology has started to take advantage of this information. This overview shows how pharmacogenomic databases have expanded in the treatment of skin diseases and provides a list of current dermatologic drugs with their FDA-approved biomarkers and clinical implementation.
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Affiliation(s)
- Le Hanh Dung Do
- a Pham Ngoc Thach University of Medicine , Ho Chi Minh city , Vietnam
| | - Howard Maibach
- b Department of Dermatology, School of Medicine , University of California , San Francisco , CA , USA
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61
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van der Wouden CH, Bank PCD, Özokcu K, Swen JJ, Guchelaar HJ. Pharmacist-Initiated Pre-Emptive Pharmacogenetic Panel Testing with Clinical Decision Support in Primary Care: Record of PGx Results and Real-World Impact. Genes (Basel) 2019; 10:E416. [PMID: 31146504 PMCID: PMC6628264 DOI: 10.3390/genes10060416] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 12/16/2022] Open
Abstract
Logistics and (cost-)effectiveness of pharmacogenetic (PGx)-testing may be optimized when delivered through a pre-emptive panel-based approach, within a clinical decision support system (CDSS). Here, clinical recommendations are automatically deployed by the CDSS when a drug-gene interaction (DGI) is encountered. However, this requires record of PGx-panel results in the electronic medical record (EMR). Several studies indicate promising clinical utility of panel-based PGx-testing in polypharmacy and psychiatry, but is undetermined in primary care. Therefore, we aim to quantify both the feasibility and the real-world impact of this approach in primary care. Within a prospective pilot study, community pharmacists were provided the opportunity to request a panel of eight pharmacogenes to guide drug dispensing within a CDSS for 200 primary care patients. In this side-study, this cohort was cross-sectionally followed-up after a mean of 2.5-years. PGx-panel results were successfully recorded in 96% and 68% of pharmacist and general practitioner (GP) EMRs, respectively. This enabled 97% of patients to (re)use PGx-panel results for at least one, and 33% for up to four newly initiated prescriptions with possible DGIs. A total of 24.2% of these prescriptions had actionable DGIs, requiring pharmacotherapy adjustment. Healthcare utilization seemed not to vary among those who did and did not encounter a DGI. Pre-emptive panel-based PGx-testing is feasible and real-world impact is substantial in primary care.
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Affiliation(s)
- Cathelijne H. van der Wouden
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| | - Paul C. D. Bank
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| | - Kübra Özokcu
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG Utrecht, The Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
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62
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Krumm N, Shirts BH. Technical, Biological, and Systems Barriers for Molecular Clinical Decision Support. Clin Lab Med 2019; 39:281-294. [PMID: 31036281 DOI: 10.1016/j.cll.2019.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Genome-enabled or molecular clinical decision support (CDS) systems provide unique advantages for the clinical use of genomic data; however, their implementation is complicated by technical, biological, and systemic barriers. This article reviews the substantial technical progress that has been made in the past decade and finds that the underlying biological limitations of genomics as well as systemic barriers to adoption of molecular CDS have been comparatively underestimated. A hybrid consultative CDS system, which integrates a genomics consultant into an active CDS system, may provide an interim path forward.
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Affiliation(s)
- Niklas Krumm
- Department of Laboratory Medicine, University of Washington, Box 357110, 1959 Northeast Pacific Street, NW120, Seattle, WA 98195-7110, USA.
| | - Brian H Shirts
- Department of Laboratory Medicine, University of Washington, Box 357110, 1959 Northeast Pacific Street, NW120, Seattle, WA 98195-7110, USA
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63
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Giannopoulou E, Katsila T, Mitropoulou C, Tsermpini EE, Patrinos GP. Integrating Next-Generation Sequencing in the Clinical Pharmacogenomics Workflow. Front Pharmacol 2019; 10:384. [PMID: 31024324 PMCID: PMC6460422 DOI: 10.3389/fphar.2019.00384] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/27/2019] [Indexed: 12/12/2022] Open
Abstract
Pharmacogenomics has been recognized as a fundamental tool in the era of personalized medicine with up to 266 drug labels, approved by major regulatory bodies, currently containing pharmacogenomics information. Next-generation sequencing analysis assumes a critical role in personalized medicine, providing a comprehensive profile of an individual's variome, particularly that of clinical relevance, comprising of pathogenic variants and pharmacogenomic biomarkers. Here, we propose a strategy to integrate next-generation sequencing into the current clinical pharmacogenomics workflow from deep resequencing to pharmacogenomics consultation, according to the existing guidelines and recommendations.
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Affiliation(s)
| | - Theodora Katsila
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | | | | | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece.,Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Zayed Center of Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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64
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Haidar CE, Hoffman JM, Gammal RS, Relling MV, Crews KR. Development of a postgraduate year 2 pharmacy residency in clinical pharmacogenetics. Am J Health Syst Pharm 2019; 74:409-415. [PMID: 28274984 DOI: 10.2146/ajhp160174] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The structure and development of an innovative, ASHP-accredited postgraduate year 2 (PGY2) clinical pharmacogenetics residency program are described. SUMMARY A 12-month PGY2 clinical pharmacogenetics residency was created at St. Jude Children's Research Hospital in accordance with the ASHP standards for advanced practice residencies. The purpose of this 12-month residency program is to prepare pharmacy residents to implement pharmacogenetics in clinical practice. The program helps residents develop expertise in the science of pharmacogenetics as well as an understanding of translational research, innovative pharmacy practice model development, and clinical informatics. The resident learns to optimize patient outcomes through the expert provision of evidence-based, patient-centered precision medicine as an integral part of an interprofessional team. After completing the program, residents are expected to have the clinical skills necessary to practice in the field of clinical pharmacogenetics and independently implement pharmacogenetic testing in other health-system settings. Because implementation of pharmacogenetics requires collaboration across many disciplines, residents works within an interprofessional team of physicians, nurses, informatics specialists, pharmacists, and clinical laboratory personnel to achieve program goals. Since the first resident graduated in 2012, the program has graduated 1 resident each year. Graduated residents have accepted pharmacogenetics positions at major academic medical centers and community hospitals, as well as academic and research positions with a pharmacogenetics emphasis. CONCLUSION A PGY2 clinical pharmacogenetics residency was successfully developed at St. Jude in 2013. After completion of the program, residents are equipped with the clinical skills and necessary experience to drive precision medicine forward and lead the implementation of pharmacogenetic testing in other healthcare settings.
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Affiliation(s)
- Cyrine E Haidar
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, TN
| | - Roseann S Gammal
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, TN
| | - Mary V Relling
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, TN
| | - Kristine R Crews
- Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, TN
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65
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Bakhtiar MF, Too CL, Tang MM, Sulaiman S, Tan LK, Ahmad-Fauzi NA, Kwok FY, Murad S, Rayyapa GC. Incidental pharmacogenetics findings in an HLA-related research: Considerations for primary prevention. Clin Exp Allergy 2019; 49:537-540. [PMID: 30693574 PMCID: PMC6849724 DOI: 10.1111/cea.13347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Mohammed Faizal Bakhtiar
- Allergy Unit, Allergy & Immunology Research Center, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Chun-Lai Too
- Immunogenetic Unit, Allergy & Immunology Research Center, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Min-Moon Tang
- Department of Dermatology, Kuala Lumpur Hospital, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Salsabil Sulaiman
- Immunogenetic Unit, Allergy & Immunology Research Center, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Lay-Kim Tan
- Immunogenetic Unit, Allergy & Immunology Research Center, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Aain Ahmad-Fauzi
- Immunogenetic Unit, Allergy & Immunology Research Center, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Fan-Yin Kwok
- Anesthetic Allergy Clinic, Department of Anesthesia and Intensive Care, Kuala Lumpur Hospital, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Shahnaz Murad
- Office of the Deputy Director General of Health (Research and Technical), Ministry of Health Malaysia, Putrajaya, Malaysia
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66
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Fulton CR, Zang Y, Desta Z, Rosenman MB, Holmes AM, Decker BS, Zhang Y, T Callaghan J, Pratt VM, Levy KD, Gufford BT, Dexter PR, Skaar TC, Eadon MT. Drug-gene and drug-drug interactions associated with tramadol and codeine therapy in the INGENIOUS trial. Pharmacogenomics 2019; 20:397-408. [PMID: 30784356 DOI: 10.2217/pgs-2018-0205] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Tramadol and codeine are metabolized by CYP2D6 and are subject to drug-gene and drug-drug interactions. Methods: This interim analysis examined prescribing behavior and efficacy in 102 individuals prescribed tramadol or codeine while receiving pharmaco-genotyping as part of the INGENIOUS trial (NCT02297126). Results: Within 60 days of receiving tramadol or codeine, clinicians more frequently prescribed an alternative opioid in ultrarapid and poor metabolizers (odds ratio: 19.0; 95% CI: 2.8-160.4) as compared with normal or indeterminate metabolizers (p = 0.01). After adjusting the CYP2D6 activity score for drug-drug interactions, uncontrolled pain was reported more frequently in individuals with reduced CYP2D6 activity (odds ratio: 0.50; 95% CI: 0.25-0.94). Conclusion: Phenoconversion for drug-drug and drug-gene interactions is an important consideration in pharmacogenomic implementation; drug-drug interactions may obscure the potential benefits of genotyping.
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Affiliation(s)
- Cathy R Fulton
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Health Informatics, Indiana University School of Informatics and Computing, Indianapolis, IN 46202, USA
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Zeruesenay Desta
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Marc B Rosenman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Ann M Holmes
- Richard M Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis, IN 46202, USA
| | - Brian S Decker
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yifei Zhang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - John T Callaghan
- Regenstrief Institute for Health Care, Indianapolis, IN 46202, USA
| | - Victoria M Pratt
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kenneth D Levy
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Brandon T Gufford
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Paul R Dexter
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Richard L Roudebush Veteran Affairs Medical Center, Indianapolis, IN 46202, USA
| | - Todd C Skaar
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Michael T Eadon
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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67
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Assessment of provider-perceived barriers to clinical use of pharmacogenomics during participation in an institutional implementation study. Pharmacogenet Genomics 2019; 29:31-38. [DOI: 10.1097/fpc.0000000000000362] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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68
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Rettig ID, Van J, Brauer JB, Luo W, McCormick TM. Tellurorhodamine photocatalyzed aerobic oxidation of organo-silanes and phosphines by visible-light. Dalton Trans 2019; 48:5665-5673. [PMID: 30968906 DOI: 10.1039/c9dt00487d] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Tellurorhodamine, 9-mesityl-3,6-bis(dimethylamino)telluroxanthylium hexafluorophosphate (1), photocatalytically oxidizes aromatic and aliphatic silanes and triphenyl phosphine under mild aerobic conditions. Under irradiation with visible light, 1 can react with self-sensitized 1O2 to generate the active telluroxide oxidant (2). Silanes are oxidized to silanols and triphenyl phosphine is oxidized to triphenyl phoshine oxide either using 2, or 1 with aerobic irradiation. Kinetic experiments coupled with a computational study elucidate possible mechanisms of oxidation for both silane and phosphine substrates. First-order rates were observed in the oxidation of triphenyl phosphine and methyldiphenyl silane, indicating a substitution like mechanism for substrate binding to the oxidized tellurium(iv). Additionally, these reactions exhibited a rate-dependence on water. Oxidations were typically run in 50 : 50 water/methanol, however, the absence of water decreased the rates of silane oxidation to a greater degree than triphenyl phosphine oxidation. Parallel results were observed in solvent kinetic isotope experiments using D2O in the solvent mixture. The rates of oxidation were slowed to a greater degree in silane oxidation by 2 (kH/kD = 17.30) than for phosphine (kH/kD = 6.20). Various silanes and triphenyl phosphine were photocatalytically oxidized with 1 (5%) under irradiation with warm white LEDs using atmospheric oxygen as the terminal oxidant.
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Affiliation(s)
- Irving D Rettig
- Department of Chemistry, Portland State University, Portland, Oregon 97201, USA.
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69
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Gammal RS, Dunnenberger HM, Caudle KE, Swen JJ. Pharmacogenomics Education and Clinical Practice Guidelines. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00015-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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70
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Goodspeed A, Kostman N, Kriete TE, Longtine JW, Smith SM, Marshall P, Williams W, Clark C, Blakeslee WW. Leveraging the utility of pharmacogenomics in psychiatry through clinical decision support: a focus group study. Ann Gen Psychiatry 2019; 18:13. [PMID: 31413721 PMCID: PMC6688280 DOI: 10.1186/s12991-019-0237-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pharmacogenomics is starting to build momentum in clinical utility, perhaps the most in mental and behavioral healthcare. However, efficient delivery of this information to the point of prescribing remains a significant challenge. Clinical decision support has an opportunity to address this void by integrating pharmacogenomics into the clinician workflow. METHODS To address the specific needs of mental health clinicians at the point of care, we conducted 3 focus groups with a total of 16 mental health clinicians. Each 1-h focus group was designed to identify the desired clinical decision support features, with a particular interest in pharmacogenomics, and potential negative or unintended consequences of clinical decision support integration at the point of care in a mental healthcare setting. We implemented an iterative design to expand upon knowledge generated in prior focus groups. The results from the guided discussion in the first focus group were used to develop a mental health clinical decision support prototype. This prototype was then presented during the next two focus groups to drive the discussion. RESULTS This study has identified main themes related to the desired clinical decision support features of mental health clinicians, the use of pharmacogenomics in practice, and unintended and negative consequences of clinical decision support integration at the point of care. Clinicians desire a more complete picture of the medication history of patients and guidance to choose medications in relation to cost, insurance coverage, and pharmacogenetics interactions. Mental health clinicians agreed that pharmacogenetics is useful and impacts their prescribing decisions when the data are available. Several negative consequences of clinical decision support integration were identified including alert fatigue and frustration using the tool. Several points of contention were related to the integration of the clinical decision support with the electronic health record, including bidirectional flow of information, speed, location within workflow, and potential incompleteness of information. CONCLUSIONS We have identified general and unique considerations of mental health clinicians with regard to clinical decision support. Clinical decision support that incorporates desired features while avoiding negative and unintended consequences will increase clinician usage and will have the potential to improve the care of patients.
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Affiliation(s)
| | - Nicolas Kostman
- RxRevu, Inc, 2601 Blake Street Suite 450, Denver, CO 80205 USA
| | | | - Joel W Longtine
- RxRevu, Inc, 2601 Blake Street Suite 450, Denver, CO 80205 USA
| | - Sean M Smith
- RxRevu, Inc, 2601 Blake Street Suite 450, Denver, CO 80205 USA
| | | | - Wesley Williams
- 2The Mental Health Center of Denver, 4141 E Dickenson Pl, Denver, CO 80222 USA
| | - Cheryl Clark
- 2The Mental Health Center of Denver, 4141 E Dickenson Pl, Denver, CO 80222 USA
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71
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Cole AM, Stephens KA, West I, Keppel GA, Thummel K, Baldwin LM. Use of electronic health record data from diverse primary care practices to identify and characterize patients' prescribed common medications. Health Informatics J 2018; 26:172-180. [PMID: 30526246 DOI: 10.1177/1460458218813640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We use prescription of statin medications and prescription of warfarin to explore the capacity of electronic health record data to (1) describe cohorts of patients prescribed these medications and (2) identify cohorts of patients with evidence of adverse events related to prescription of these medications. This study was conducted in the WWAMI region Practice and Research Network (WPRN)., a network of primary care practices across Washington, Wyoming, Alaska, Montana and Idaho DataQUEST, an electronic data-sharing infrastructure. We used electronic health record data to describe cohorts of patients prescribed statin or warfarin medications and reported the proportions of patients with adverse events. Among the 35,445 active patients, 1745 received at least one statin prescription and 301 received at least one warfarin prescription. Only 3 percent of statin patients had evidence of myopathy; 51 patients (17% of those prescribed warfarin) had a bleeding complication. Primary-care electronic health record data can effectively be used to identify patients prescribed specific medications and patients potentially experiencing medication adverse events.
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Affiliation(s)
| | | | | | - Gina A Keppel
- University of Washington, USA; Institute of Translational Health Sciences, USA
| | | | - Laura-Mae Baldwin
- University of Washington, USA; Institute of Translational Health Sciences, USA
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72
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Chambliss AB, Marzinke MA. Clinical Pharmacogenetics for Precision Medicine: Successes and Setbacks. J Appl Lab Med 2018; 3:474-486. [PMID: 33636912 DOI: 10.1373/jalm.2017.023127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/05/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pharmacogenetics is a key component in the delivery of therapeutics to maximize pharmacologic efficacy and minimize toxicity. There are numerous identified gene-drug pairs that demonstrate the utility of pharmacogenetics testing for drug or dose selection. Although some of these pairs have translated into clinical use, pharmacogenetic testing has not yet made its way into routine clinical practice at many institutions. CONTENT This review provides an overview of clinically actionable pharmacogenetics in precision medicine. Examples of successfully implemented gene-drug pairs, along with common testing methodologies and guidelines for application, are discussed. Remaining barriers to widespread clinical implementation are also examined. SUMMARY There is a recognized role for genotyping in the guidance of therapeutic drug regimens and the prevention of adverse drug reactions. Evidence-based guidelines are available to aid in the selection of treatment upon pharmacogenetics testing for established gene-drug pairs. Multidisciplinary clinical collaboration and clinical decision support tools will be critical for widespread adoption, and financial reimbursement barriers remain.
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Affiliation(s)
- Allison B Chambliss
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark A Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
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73
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Vassy JL, Chun S, Advani S, Ludin SA, Smith JG, Alligood EC. Impact of SLCO1B1 Pharmacogenetic Testing on Patient and Healthcare Outcomes: A Systematic Review. Clin Pharmacol Ther 2018; 106:360-373. [PMID: 30137643 DOI: 10.1002/cpt.1223] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022]
Abstract
Demonstrated improvements in patient outcomes will facilitate the clinical implementation of pharmacogenetic testing. Using the association between solute carrier organic anion transporter family member 1B1 (SLCO1B1) and statin-associated muscle symptoms (SAMSs) as a model, we conducted a systematic review of patient outcomes after delivery of SLCO1B1 results. Using PubMed and Embase searches through December 19, 2017, we identified 37 eligible records reporting preliminary or final outcomes, including six studies delivering only SLCO1B1 results and five large healthcare system-based implementation projects of multipharmacogene panels. Two small trials have demonstrated at least short-term improvements in low-density lipoprotein cholesterol after SLCO1B1 testing among previously statin intolerant patients. Evidence from large implementation projects suggests that SLCO1B1 results may change prescribing patterns for some high-risk patients. No study has reported improvements in SAMSs or cardiovascular events or tracked the economic outcomes of SLCO1B1 testing. Ongoing studies should collect and report outcomes relevant to pharmacogenetics stakeholders.
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Affiliation(s)
- Jason L Vassy
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sojeong Chun
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA.,Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts, USA
| | - Sanjay Advani
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Sophie A Ludin
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA.,Cornell University, Ithaca, New York, USA
| | - Jason G Smith
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Elaine C Alligood
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA
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74
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Klein MD, Lee CR, Stouffer GA. Clinical outcomes of CYP2C19 genotype-guided antiplatelet therapy: existing evidence and future directions. Pharmacogenomics 2018; 19:1039-1046. [DOI: 10.2217/pgs-2018-0072] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
It is well established that the CYP2C19 nonfunctional *2 and *3 polymorphisms impair the bioactivation and antiplatelet effects of clopidogrel, and increase the risk of adverse cardiovascular events following percutaneous coronary intervention. In contrast, CYP2C19 genotype does not impact clinical response to prasugrel or ticagrelor. Recent studies have evaluated the impact of CYP2C19 genotype-guided selection of antiplatelet therapy on clinical outcomes and begun to close some of the gaps in knowledge and uncertainty that have impeded widespread clinical implementation of this precision medicine approach. This review will critically evaluate recent data and offer new insight into the potential clinical utility of genotype-guided antiplatelet therapy in the context of current clinical practice guidelines.
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Affiliation(s)
- Melissa D Klein
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig R Lee
- McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Pharmacotherapy & Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Pharmacogenomics & Individualized Therapy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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75
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Guchelaar HJ. Pharmacogenomics, a novel section in the European Journal of Human Genetics. Eur J Hum Genet 2018; 26:1399-1400. [PMID: 29967335 DOI: 10.1038/s41431-018-0205-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- Henk-Jan Guchelaar
- Dept. Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands.
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76
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Blagec K, Koopmann R, Crommentuijn – van Rhenen M, Holsappel I, van der Wouden CH, Konta L, Xu H, Steinberger D, Just E, Swen JJ, Guchelaar HJ, Samwald M. Implementing pharmacogenomics decision support across seven European countries: The Ubiquitous Pharmacogenomics (U-PGx) project. J Am Med Inform Assoc 2018; 25:893-898. [PMID: 29444243 PMCID: PMC6016647 DOI: 10.1093/jamia/ocy005] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/23/2017] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Abstract
Clinical pharmacogenomics (PGx) has the potential to make pharmacotherapy safer and more effective by utilizing genetic patient data for drug dosing and selection. However, widespread adoption of PGx depends on its successful integration into routine clinical care through clinical decision support tools, which is often hampered by insufficient or fragmented infrastructures. This paper describes the setup and implementation of a unique multimodal, multilingual clinical decision support intervention consisting of digital, paper-, and mobile-based tools that are deployed across implementation sites in seven European countries participating in the Ubiquitous PGx (U-PGx) project.
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Affiliation(s)
- Kathrin Blagec
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna, Vienna, Austria
| | - Rudolf Koopmann
- bio.logis Genetic Information Management GmbH, Frankfurt am Main, Germany
| | | | - Inge Holsappel
- Medicines Information Centre; Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | | | - Lidija Konta
- bio.logis Center for Human Genetics, Frankfurt am Main, Germany
| | - Hong Xu
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna, Vienna, Austria
| | - Daniela Steinberger
- bio.logis Genetic Information Management GmbH, Frankfurt am Main, Germany
- bio.logis Center for Human Genetics, Frankfurt am Main, Germany
- Institute for Human Genetics, Justus Liebig University, Giessen, Germany
| | - Enrico Just
- bio.logis Genetic Information Management GmbH, Frankfurt am Main, Germany
| | - Jesse J Swen
- Deptartment of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Deptartment of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias Samwald
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna, Vienna, Austria
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77
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Caudle KE, Keeling NJ, Klein TE, Whirl-Carrillo M, Pratt VM, Hoffman JM. Standardization can accelerate the adoption of pharmacogenomics: current status and the path forward. Pharmacogenomics 2018; 19:847-860. [PMID: 29914287 DOI: 10.2217/pgs-2018-0028] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Successfully implementing pharmacogenomics into routine clinical practice requires an efficient process to order genetic tests and report the results to clinicians and patients. Lack of standardized approaches and terminology in clinical laboratory processes, ordering of the test and reporting of test results all impede this workflow. Expert groups such as the Association for Molecular Pathology and the Clinical Pharmacogenetics Implementation Consortium have published recommendations for standardizing laboratory genetic testing, reporting and terminology. Other resources such as PharmGKB, ClinVar, ClinGen and PharmVar have established databases of nomenclature for pharmacogenetic alleles and variants. Opportunities remain to develop new standards and further disseminate existing standards which will accelerate the implementation of pharmacogenomics.
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Affiliation(s)
- Kelly E Caudle
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Nicholas J Keeling
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA.,Department of Pharmacy Administration, University of Mississippi School of Pharmacy, Oxford, MS 38655, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA 94305, USA
| | | | - Victoria M Pratt
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James M Hoffman
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA.,Office of Quality & Patient Care, St Jude Children's Research Hospital, Memphis, TN 38105, USA
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Abstract
Considerable interindividual variability in response to cardiovascular pharmacotherapy exists with drug responses varying from being efficacious to inadequate to induce severe adverse events. Fueled by advancements and multidisciplinary collaboration across disciplines such as genetics, bioinformatics, and basic research, the vision of personalized medicine, rather than a one-size-fits-all approach, may be within reach. Pharmacogenetics offers the potential to optimize the benefit-risk profile of drugs by tailoring diagnostic and treatment strategies according to the individual patient. To date, a multitude of studies has tried to delineate the effects of gene-drug interactions for drugs commonly used to treat cardiovascular-related disease. The focus of this review is on how genetic variability may modify drug responsiveness and patient outcomes following therapy with commonly used cardiovascular drugs including clopidogrel, warfarin, statins, and β-blockers. Also included are examples of how genetic studies can be used to guide drug discovery and examples of how genetic information may be deployed in clinical decision making.
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Affiliation(s)
- Peter E Weeke
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
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79
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Roden DM, Van Driest SL, Mosley JD, Wells QS, Robinson JR, Denny JC, Peterson JF. Benefit of Preemptive Pharmacogenetic Information on Clinical Outcome. Clin Pharmacol Ther 2018; 103:787-794. [PMID: 29377064 PMCID: PMC6134843 DOI: 10.1002/cpt.1035] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 12/13/2022]
Abstract
The development of new knowledge around the genetic determinants of variable drug action has naturally raised the question of how this new knowledge can be used to improve the outcome of drug therapy. Two broad approaches have been taken: a point-of-care approach in which genotyping for specific variant(s) is undertaken at the time of drug prescription, and a preemptive approach in which multiple genetic variants are typed in an individual patient and the information archived for later use when a drug with a "pharmacogenetic story" is prescribed. This review addresses the current state of implementation, the rationale for these approaches, and barriers that must be overcome. Benefits to pharmacogenetic testing are only now being defined and will be discussed.
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Affiliation(s)
- Dan M. Roden
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Pharmacology, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
| | - Sara L. Van Driest
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center Nashville, TN
| | - Jonathan D. Mosley
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
| | - Quinn S. Wells
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
| | - Jamie R. Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
- Department of Surgery, Vanderbilt University Medical Center Nashville, TN
| | - Joshua C. Denny
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
| | - Josh F. Peterson
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
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80
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Overby CL, Thompkins P, Lehmann H, Chute CG, Sheffield JS. Value of Genetics-informed Drug Dosing Guidance in Pregnant Women: A Needs Assessment with Obstetric Healthcare Providers at Johns Hopkins. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2017:1342-1351. [PMID: 29854203 PMCID: PMC5977707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In order to better understand the potential value of genetics-informed drug dose guidance to obstetric healthcare providers at Johns Hopkins we administered a web-based needs assessment survey. The survey included questions about: 1) experience with adjusting drug doses during pregnancy; 2) comfort prescribing medications to pregnant women with chronic conditions; 3) awareness and use of genetics-informed dosing guidance; and 4) perceived value of access to services to provide genetics-informed dosing guidance. Among thirty-one respondents, 81% indicated an interest in access to genetics-informed drug dose guidance, particularly a mobile or electronic health record (EHR) application. It was indicated, however, that genetics is one of many characteristics that influence dose adjustments during pregnancy. This study motivates future research to help obstetric healthcare providers tailor drug dose to individual patients based upon models integrating multiple patient characteristics, including genetics.
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Affiliation(s)
- Casey L Overby
- Division of General Internal Medicine
- Institute for Clinical & Translational Research
- Division of Health Sciences Informatics
| | | | | | - Christopher G Chute
- Division of General Internal Medicine
- Institute for Clinical & Translational Research
- Division of Health Sciences Informatics
| | - Jeanne S Sheffield
- Division of Maternal & Fetal Medicine; Johns Hopkins University School of Medicine, Baltimore, MD, USA
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81
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Swen JJ, Nijenhuis M, van Rhenen M, de Boer-Veger NJ, Buunk AM, Houwink EJF, Mulder H, Rongen GA, van Schaik RHN, van der Weide J, Wilffert B, Deneer VHM, Guchelaar HJ. Pharmacogenetic Information in Clinical Guidelines: The European Perspective. Clin Pharmacol Ther 2018; 103:795-801. [PMID: 29460273 DOI: 10.1002/cpt.1049] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 12/13/2022]
Abstract
Surveys among pharmacists and physicians show that these healthcare professionals have successfully adopted the concept of pharmacogenomics (PGx).1-3 In addition, patients are willing to consent to participate in PGx implementation studies.4 However, the surveys also show that healthcare professionals do not frequently order or recommend a PGx test.1,2 Among others, a frequently perceived hurdle for clinical uptake of PGx is the availability of guidelines translating PGx test results into clinical actions for individual patients.5,6.
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Affiliation(s)
- Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Centre, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marga Nijenhuis
- Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | - Mandy van Rhenen
- Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | | | | | - Elisa J F Houwink
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Mulder
- Department of Clinical Pharmacy, Wilhelmina Hospital, Assen, The Netherlands
| | - Gerard A Rongen
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan van der Weide
- Department of Clinical Chemistry, St. Jansdal Hospital, Harderwijk, The Netherlands
| | - Bob Wilffert
- Department of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen and Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Vera H M Deneer
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Centre, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden University Medical Centre, Leiden, The Netherlands
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82
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Ubanyionwu S, Formea CM, Anderson B, Wix K, Dierkhising R, Caraballo PJ. Evaluation of prescriber responses to pharmacogenomics clinical decision support for thiopurine S-methyltransferase testing. Am J Health Syst Pharm 2018; 75:191-198. [PMID: 29436466 DOI: 10.2146/ajhp170280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Results of a study of prescribers' responses to a pharmacogenomics-based clinical decision support (CDS) alert designed to prompt thiopurine S-methyltransferase (TPMT) status testing are reported. METHODS A single-center, retrospective, chart review-based study was conducted to evaluate prescriber compliance with a pretest CDS alert that warned of potential thiopurine drug toxicity resulting from deficient TPMT activity due to TPMT gene polymorphism. The CDS alert was triggered when prescribers ordered thiopurine drugs for patients whose records did not indicate TPMT status or when historical thiopurine use was documented in the electronic health record. The alert pop-up also provided a link to online educational resources to guide thiopurine dosing calculations. RESULTS During the 9-month study period, 500 CDS alerts were generated: in 101 cases (20%), TPMT phenotyping or TPMT genotyping was ordered; in 399 cases (80%), testing was not ordered. Multivariable regression analysis indicated that documentation of historical thiopurine use was the only independent predictor of test ordering. Among the 99 patients tested subsequent to CDS alerts, 70 (71%) had normal TPMT activity, 29 (29%) had intermediate activity, and none had deficient activity. The online resources provided thiopurine dosing recommendations applicable to 24 patients, but only 3 were prescribed guideline-supported doses after CDS alerts. CONCLUSION The pretest CDS rule resulted in a large proportion of neglected alerts due to poor alerting accuracy and consequent alert fatigue. Prescriber usage of online thiopurine dosing resources was low.
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Affiliation(s)
| | | | | | - Kelly Wix
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN
| | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Pedro J Caraballo
- Department of Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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83
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Hicks JK, Dunnenberger HM, Gumpper KF, Haidar CE, Hoffman JM. Integrating pharmacogenomics into electronic health records with clinical decision support. Am J Health Syst Pharm 2018; 73:1967-1976. [PMID: 27864204 DOI: 10.2146/ajhp160030] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Existing pharmacogenomic informatics models, key implementation steps, and emerging resources to facilitate the development of pharmacogenomic clinical decision support (CDS) are described. SUMMARY Pharmacogenomics is an important component of precision medicine. Informatics, especially CDS in the electronic health record (EHR), is a critical tool for the integration of pharmacogenomics into routine patient care. Effective integration of pharmacogenomic CDS into the EHR can address implementation challenges, including the increasing volume of pharmacogenomic clinical knowledge, the enduring nature of pharmacogenomic test results, and the complexity of interpreting results. Both passive and active CDS provide point-of-care information to clinicians that can guide the systematic use of pharmacogenomics to proactively optimize pharmacotherapy. Key considerations for a successful implementation have been identified; these include clinical workflows, identification of alert triggers, and tools to guide interpretation of results. These considerations, along with emerging resources from the Clinical Pharmacogenetics Implementation Consortium and the National Academy of Medicine, are described. CONCLUSION The EHR with CDS is essential to curate pharmacogenomic data and disseminate patient-specific information at the point of care. As part of the successful implementation of pharmacogenomics into clinical settings, all relevant clinical recommendations pertaining to gene-drug pairs must be summarized and presented to clinicians in a manner that is seamlessly integrated into the clinical workflow of the EHR. In some situations, ancillary systems and applications outside the EHR may be integrated to augment the capabilities of the EHR.
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Affiliation(s)
- J Kevin Hicks
- DeBartolo Family Personalized Medicine Institute and Department of Population Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Karl F Gumpper
- Department of Pharmacy, Boston Children's Hospital, Boston, MA
| | - Cyrine E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN.
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84
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Dunnenberger HM, Biszewski M, Bell GC, Sereika A, May H, Johnson SG, Hulick PJ, Khandekar J. Implementation of a multidisciplinary pharmacogenomics clinic in a community health system. Am J Health Syst Pharm 2018; 73:1956-1966. [PMID: 27864203 DOI: 10.2146/ajhp160072] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The development and implementation of a multidisciplinary pharmacogenomics clinic within the framework of an established community-based medical genetics program are described. SUMMARY Pharmacogenomics is an important component of precision medicine that holds considerable promise for pharmacotherapy optimization. As part of the development of a health system-wide integrated pharmacogenomics program, in early 2015 Northshore University Health-System established a pharmacogenomics clinic run by a multidisciplinary team including a medical geneticist, a pharmacist, a nurse practitioner, and genetic counselors. The team identified five key program elements: (1) a billable-service provider, (2) a process for documentation of relevant medication and family histories, (3) personnel with the knowledge required to interpret pharmacogenomic results, (4) personnel to discuss risks, benefits, and limitations of pharmacogenomic testing, and (5) a mechanism for reporting results. The most important program component is expert interpretation of genetic test results to provide clinically useful information; pharmacists are well positioned to provide that expertise. At the Northshore University HealthSystem pharmacogenomics clinic, patient encounters typically entail two one-hour visits and follow a standardized workflow. At the first visit, pharmacogenomics-focused medication and family histories are obtained, risks and benefits of genetic testing are explained, and a test sample is collected; at the second visit, test results are provided along with evidence-based pharmacotherapy recommendations. CONCLUSION A multidisciplinary clinic providing genotyping and related services can facilitate the integration of pharmacogenomics into clinical care and meet the needs of early adopters of precision medicine.
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Affiliation(s)
- Henry M Dunnenberger
- Center for Molecular Medicine, NorthShore University HealthSystem, Evanston, IL.
| | - Matthew Biszewski
- Thrombosis and Anticoagulation Unit, NorthShore University HealthSystem, Glenview, IL
| | | | - Annette Sereika
- Center for Molecular Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Holley May
- Center for Medical Genetics, NorthShore University HealthSystem, Evanston, IL
| | | | - Peter J Hulick
- Center for Medical Genetics, NorthShore University HealthSystem, Evanston, IL
| | - Janardan Khandekar
- Center for Molecular Medicine, NorthShore University HealthSystem, Evanston, IL
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85
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Aka I, Bernal CJ, Carroll R, Maxwell-Horn A, Oshikoya KA, Van Driest SL. Clinical Pharmacogenetics of Cytochrome P450-Associated Drugs in Children. J Pers Med 2017; 7:jpm7040014. [PMID: 29099060 PMCID: PMC5748626 DOI: 10.3390/jpm7040014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 10/26/2017] [Accepted: 10/26/2017] [Indexed: 01/23/2023] Open
Abstract
Cytochrome P450 (CYP) enzymes are commonly involved in drug metabolism, and genetic variation in the genes encoding CYPs are associated with variable drug response. While genotype-guided therapy has been clinically implemented in adults, these associations are less well established for pediatric patients. In order to understand the frequency of pediatric exposures to drugs with known CYP interactions, we compiled all actionable drug-CYP interactions with a high level of evidence using Clinical Pharmacogenomic Implementation Consortium (CPIC) data and surveyed 10 years of electronic health records (EHR) data for the number of children exposed to CYP-associated drugs. Subsequently, we performed a focused literature review for drugs commonly used in pediatrics, defined as more than 5000 pediatric patients exposed in the decade-long EHR cohort. There were 48 drug-CYP interactions with a high level of evidence in the CPIC database. Of those, only 10 drugs were commonly used in children (ondansetron, oxycodone, codeine, omeprazole, lansoprazole, sertraline, amitriptyline, citalopram, escitalopram, and risperidone). For these drugs, reports of the drug-CYP interaction in cohorts including children were sparse. There are adequate data for implementation of genotype-guided therapy for children for three of the 10 commonly used drugs (codeine, omeprazole and lansoprazole). For the majority of commonly used drugs with known CYP interactions, more data are required to support pharmacogenomic implementation in children.
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Affiliation(s)
- Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Christiana J Bernal
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Robert Carroll
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Angela Maxwell-Horn
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Kazeem A Oshikoya
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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O’Donnell PH, Wadhwa N, Danahey K, Borden BA, Lee SM, Hall JP, Klammer C, Hussain S, Siegler M, Sorrentino MJ, Davis AM, Sacro YA, Nanda R, Polonsky TS, Koyner JL, Burnet DL, Lipstreuer K, Rubin DT, Mulcahy C, Strek ME, Harper W, Cifu AS, Polite B, Patrick-Miller L, Yeo KTJ, Leung EKY, Volchenboum SL, Altman RB, Olopade OI, Stadler WM, Meltzer DO, Ratain MJ. Pharmacogenomics-Based Point-of-Care Clinical Decision Support Significantly Alters Drug Prescribing. Clin Pharmacol Ther 2017; 102:859-869. [PMID: 28398598 PMCID: PMC5636653 DOI: 10.1002/cpt.709] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/31/2017] [Accepted: 04/05/2017] [Indexed: 12/22/2022]
Abstract
Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively studied medication changes made by providers representing eight different medicine specialty clinics whose patients had submitted to preemptive pharmacogenomic genotyping. An institutional clinical decision support (CDS) system provided pharmacogenomic results using traffic light alerts: green = genomically favorable, yellow = genomic caution, red = high risk. The influence of pharmacogenomic alerts on prescribing behaviors was the primary endpoint. In all, 2,279 outpatient encounters were analyzed. Independent of other potential prescribing mediators, medications with high pharmacogenomic risk were changed significantly more often than prescription drugs lacking pharmacogenomic information (odds ratio (OR) = 26.2 (9.0-75.3), P < 0.0001). Medications with cautionary pharmacogenomic information were also changed more frequently (OR = 2.4 (1.7-3.5), P < 0.0001). No pharmacogenomically high-risk medications were prescribed during the entire study when physicians consulted the CDS tool. Pharmacogenomic information improved prescribing in patterns aimed at reducing patient risk, demonstrating that enhanced prescription decision-making is achievable through clinical integration of genomic medicine.
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Affiliation(s)
- Peter H. O’Donnell
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, U.S.A
| | - Nisha Wadhwa
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, U.S.A
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
- Center for Research Informatics, The University of Chicago, Chicago, IL, U.S.A
| | - Brittany A. Borden
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Sang Mee Lee
- Department of Health Sciences, The University of Chicago, Chicago, IL, U.S.A
| | - Julianne P. Hall
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Catherine Klammer
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Sheena Hussain
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Mark Siegler
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, U.S.A
- MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, U.S.A
| | - Matthew J. Sorrentino
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Andrew M. Davis
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Yasmin A. Sacro
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Rita Nanda
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Tamar S. Polonsky
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Jay L. Koyner
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Deborah L. Burnet
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Kristen Lipstreuer
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - David T. Rubin
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Cathleen Mulcahy
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Mary E. Strek
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, U.S.A
| | - William Harper
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Adam S. Cifu
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Blase Polite
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - Linda Patrick-Miller
- Center for Clinical Cancer Genetics, The University of Chicago, Chicago, IL, U.S.A
| | - Kiang-Teck J. Yeo
- Department of Pathology, The University of Chicago, Chicago, IL, U.S.A
| | | | | | - Russ B. Altman
- Departments of Bioengineering, Genetics, and Medicine, Stanford University, Palo Alto, CA, U.S.A
| | | | - Walter M. Stadler
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
| | - David O. Meltzer
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, U.S.A
| | - Mark J. Ratain
- Department of Medicine, The University of Chicago, Chicago, IL, U.S.A
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, U.S.A
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, U.S.A
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Moyer AM, Caraballo PJ. The challenges of implementing pharmacogenomic testing in the clinic. Expert Rev Pharmacoecon Outcomes Res 2017; 17:567-577. [PMID: 28949250 DOI: 10.1080/14737167.2017.1385395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pharmacogenomic testing has the potential to greatly benefit patients by enabling personalization of medication management, ensuring better efficacy and decreasing the risk of side effects. However, to fully realize the potential of pharmacogenomic testing, there are several important issues that must be addressed. Areas covered: In this expert review we discuss current challenges impacting the implementation of pharmacogenomic testing in the clinical practice. We emphasize issues related to testing methods, reporting of the results, test selection, clinical interpretation of the results, cost-effectiveness, and the long-term use of pharmacogenomic results in clinical practice. We identify opportunities and future directions to facilitate clinical implementation. Expert commentary: Several key elements are necessary to optimally integrate pharmacogenomic testing into clinical practice. Collaborative efforts among laboratories are needed to improve standardization of testing and reporting of the results. Clinicians need educational opportunities to improve understanding of which test to order and how to interpret the results. The electronic health records and other clinical systems need to improve their storage of the pharmacogenomics test results and interoperability to facilitate the use of clinically actionable results to improve patient care.
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Affiliation(s)
- Ann M Moyer
- a Department of Laboratory Medicine and Pathology , Mayo Clinic , Rochester , MN , USA
| | - Pedro J Caraballo
- b Department of Medicine , Mayo Clinic , Rochester , MN , USA.,c Center for Translational Informatics and Knowledge Management, Mayo Clinic , Rochester , MN , USA
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88
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Danahey K, Borden BA, Furner B, Yukman P, Hussain S, Saner D, Volchenboum SL, Ratain MJ, O'Donnell PH. Simplifying the use of pharmacogenomics in clinical practice: Building the genomic prescribing system. J Biomed Inform 2017; 75:110-121. [PMID: 28963061 DOI: 10.1016/j.jbi.2017.09.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND A barrier to the use of genomic information during prescribing is the limited number of software solutions that combine a user-friendly interface with complex medical data. We built and designed an online, secure, electronic custom interface termed the Genomic Prescribing System (GPS). METHODS Actionable pharmacogenomic (PGx) information was reviewed, collected, and stored in the back-end of GPS to enable creation of customized drug- and variant-specific clinical decision support (CDS) summaries. The database architecture utilized the star schema to store information. Patient raw genomic data underwent transformation via custom-designed algorithms to enable gene and phenotype-level associations. Multiple external data sets (PubMed, The Systematized Nomenclature of Medicine (SNOMED), National Drug File - Reference Terminology (ND-FRT), and a publically-available PGx knowledgebase) were integrated to facilitate the delivery of patient, drug, disease, and genomic information. Institutional security infrastructure was leveraged to securely store patient genomic and clinical data on a HIPAA-compliant server farm. RESULTS As of May 17, 2016, the GPS back-end housed 257 CDS encompassing 112 genetic variants, 42 genes, and 46 PGx-actionable drugs. The GPS user interface presented patient-specific CDS alongside a recognizable traffic light symbol (green/yellow/red), denoting PGx risk for each genomic result. The number of traffic lights per visit increased with the corresponding increase in the number of available PGx-annotated drugs over time. An integrated drug and disease search functionality, links to primary literature sources, and potential alternative PGx drugs were indicated. The system, which was initially used as stand-alone CDS software within our clinical environment, was then integrated with the institutional electronic medical record for enhanced usability. There have been nearly 2000 logins in 43months since inception, with usage exceeding 56 logins per month and system up-times of 99.99%. For all patient-provider visits encompassing >3years of implementation, unique alert click-through rates corresponded to genomic risk: red lights clicked 100%, yellow lights 79%, green lights 43%. CONCLUSIONS Successful deployment of GPS by combining complex data and recognizable iconography led to a tool that enabled point-of-care genomic delivery with high usability. Continued scalability and incorporation of additional clinical elements to be considered alongside PGx information could expand future impact.
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Affiliation(s)
- Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Brittany A Borden
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Brian Furner
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Patrick Yukman
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Sheena Hussain
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Donald Saner
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Samuel L Volchenboum
- Center for Research Informatics, University of Chicago, Chicago, IL, USA; Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Mark J Ratain
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Peter H O'Donnell
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Department of Medicine, University of Chicago, Chicago, IL, USA.
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89
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Vo TT, Bell GC, Owusu Obeng A, Hicks JK, Dunnenberger HM. Pharmacogenomics Implementation: Considerations for Selecting a Reference Laboratory. Pharmacotherapy 2017; 37:1014-1022. [DOI: 10.1002/phar.1985] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Teresa T. Vo
- Department of Pharmacotherapeutics and Clinical Research; College of Pharmacy; University of South Florida; Tampa Florida
| | - Gillian C. Bell
- Personalized Medicine Program; Mission Health; Asheville North Carolina
| | - Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine; Icahn School of Medicine at Mount Sinai; New York New York
- Pharmacy Department; The Mount Sinai Hospital; New York New York
| | - J. Kevin Hicks
- Division of Population, Science; Department of Individualized Cancer Management; DeBartolo Family Personalized Medicine Institute; Moffitt Cancer Center & Research Institute; Tampa Florida
| | - Henry M. Dunnenberger
- Center for Molecular Medicine; NorthShore University HealthSystem; Evanston Illinois
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90
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Martin S, Wagner J, Lupulescu-Mann N, Ramsey K, Cohen A, Graven P, Weiskopf NG, Dorr DA. Comparison of EHR-based diagnosis documentation locations to a gold standard for risk stratification in patients with multiple chronic conditions. Appl Clin Inform 2017; 8:794-809. [PMID: 28765864 PMCID: PMC6220706 DOI: 10.4338/aci-2016-12-ra-0210] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/31/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To measure variation among four different Electronic Health Record (EHR) system documentation locations versus 'gold standard' manual chart review for risk stratification in patients with multiple chronic illnesses. METHODS Adults seen in primary care with EHR evidence of at least one of 13 conditions were included. EHRs were manually reviewed to determine presence of active diagnoses, and risk scores were calculated using three different methodologies and five EHR documentation locations. Claims data were used to assess cost and utilization for the following year. Descriptive and diagnostic statistics were calculated for each EHR location. Criterion validity testing compared the gold standard verified diagnoses versus other EHR locations and risk scores in predicting future cost and utilization. RESULTS Nine hundred patients had 2,179 probable diagnoses. About 70% of the diagnoses from the EHR were verified by gold standard. For a subset of patients having baseline and prediction year data (n=750), modeling showed that the gold standard was the best predictor of outcomes on average for a subset of patients that had these data. However, combining all data sources together had nearly equivalent performance for prediction as the gold standard. CONCLUSIONS EHR data locations were inaccurate 30% of the time, leading to improvement in overall modeling from a gold standard from chart review for individual diagnoses. However, the impact on identification of the highest risk patients was minor, and combining data from different EHR locations was equivalent to gold standard performance. The reviewer's ability to identify a diagnosis as correct was influenced by a variety of factors, including completeness, temporality, and perceived accuracy of chart data.
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Affiliation(s)
| | | | | | | | | | | | | | - David A Dorr
- David A. Dorr, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., MDYMICE, Portland, OR 97239-3098, USA,
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91
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Khelifi M, Tarczy-Hornoch P, Devine EB, Pratt W. Design Recommendations for Pharmacogenomics Clinical Decision Support Systems. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2017; 2017:237-246. [PMID: 28815136 PMCID: PMC5543362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The use of pharmacogenomics (PGx) in clinical practice still faces challenges to fully adopt genetic information in targeting drug therapy. To incorporate genetics into clinical practice, many support the use of Pharmacogenomics Clinical Decision Support Systems (PGx-CDS) for medication prescriptions. This support was fueled by new guidelines to incorporate genetics for optimizing drug dosage and reducing adverse events. In addition, the complexity of PGx led to exploring CDS outside the paradigm of the basic CDS tools embedded in commercial electronic health records. Therefore, designing the right CDS is key to unleashing the full potential of pharmacogenomics and making it a part of clinicians' daily workflow. In this work, we 1) identify challenges and barriers of the implementation of PGx-CDS in clinical settings, 2) develop a new design approach to CDS with functional characteristics that can improve the adoption of pharmacogenomics guidelines and thus patient safety, and 3) create design guidelines and recommendations for such PGx-CDS tools.
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92
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Haylett WJ. The Relationship of Genetics, Nursing Practice, and Informatics Tools in 6-Mercaptopurine Dosing in Pediatric Oncology [Formula: see text]. J Pediatr Oncol Nurs 2017; 34:342-346. [PMID: 28681659 DOI: 10.1177/1043454217713446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
An antileukemic agent prescribed for pediatric oncology patients during the maintenance phase of therapy for acute lymphoblastic leukemia, 6-mercaptopurine (6-MP), is highly influenced by genetic variations in the thiopurine S-methyltransferase enzyme. As such, 6-MP must be dosed so that patients with 1 or 2 inactive thiopurine S-methyltransferase alleles will not incur an increased risk for myelosuppression or other toxicities. Informatics tools such as clinical decision support systems are useful for the application of this and similar pharmacogenetics information to the realm of nursing and clinical practice for safe and effective patient care. This article will discuss pharmacogenetics and the associated use of 6-MP; present implications for nursing practice; identify informatics tools such as clinical decision support systems, which can greatly enhance the care of patients whose treatment is based on critical genetic information; and examine the relationship of genetics, nursing practice, and informatics for 6-MP dosing in pediatric oncology.
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93
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Hinderer M, Boeker M, Wagner SA, Lablans M, Newe S, Hülsemann JL, Neumaier M, Binder H, Renz H, Acker T, Prokosch HU, Sedlmayr M. Integrating clinical decision support systems for pharmacogenomic testing into clinical routine - a scoping review of designs of user-system interactions in recent system development. BMC Med Inform Decis Mak 2017; 17:81. [PMID: 28587608 PMCID: PMC5461630 DOI: 10.1186/s12911-017-0480-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/30/2017] [Indexed: 01/05/2023] Open
Abstract
Background Pharmacogenomic clinical decision support systems (CDSS) have the potential to help overcome some of the barriers for translating pharmacogenomic knowledge into clinical routine. Before developing a prototype it is crucial for developers to know which pharmacogenomic CDSS features and user-system interactions have yet been developed, implemented and tested in previous pharmacogenomic CDSS efforts and if they have been successfully applied. We address this issue by providing an overview of the designs of user-system interactions of recently developed pharmacogenomic CDSS. Methods We searched PubMed for pharmacogenomic CDSS published between January 1, 2012 and November 15, 2016. Thirty-two out of 118 identified articles were summarized and included in the final analysis. We then compared the designs of user-system interactions of the 20 pharmacogenomic CDSS we had identified. Results Alerts are the most widespread tools for physician-system interactions, but need to be implemented carefully to prevent alert fatigue and avoid liabilities. Pharmacogenomic test results and override reasons stored in the local EHR might help communicate pharmacogenomic information to other internal care providers. Integrating patients into user-system interactions through patient letters and online portals might be crucial for transferring pharmacogenomic data to external health care providers. Inbox messages inform physicians about new pharmacogenomic test results and enable them to request pharmacogenomic consultations. Search engines enable physicians to compare medical treatment options based on a patient’s genotype. Conclusions Within the last 5 years, several pharmacogenomic CDSS have been developed. However, most of the included articles are solely describing prototypes of pharmacogenomic CDSS rather than evaluating them. To support the development of prototypes further evaluation efforts will be necessary. In the future, pharmacogenomic CDSS will likely include prediction models to identify patients who are suitable for preemptive genotyping. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0480-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marc Hinderer
- Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Wetterkreuz 13, 91058, Erlangen, Germany.
| | - Martin Boeker
- Medical Informatics, Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Sebastian A Wagner
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Martin Lablans
- Medical Informatics in Translational Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Stephanie Newe
- Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Wetterkreuz 13, 91058, Erlangen, Germany
| | | | - Michael Neumaier
- Institute for Clinical Chemistry, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Harald Binder
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Harald Renz
- University of Marburg, Institute of Laboratory Medicine, Marburg, Germany
| | - Till Acker
- Institute of Neuropathology, University of Giessen, Giessen, Germany
| | - Hans-Ulrich Prokosch
- Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Wetterkreuz 13, 91058, Erlangen, Germany
| | - Martin Sedlmayr
- Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Wetterkreuz 13, 91058, Erlangen, Germany
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94
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Mathias PC, Hendrix N, Wang WJ, Keyloun K, Khelifi M, Tarczy-Hornoch P, Devine B. Characterizing Pharmacogenomic-Guided Medication Use With a Clinical Data Repository. Clin Pharmacol Ther 2017; 102:340-348. [PMID: 28073152 DOI: 10.1002/cpt.611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/28/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022]
Abstract
The extent to which pharmacogenomic-guided medication use has been adopted in various health systems is unclear. To assess the uptake of pharmacogenomic-guided medication use, we determined its frequency across our health system, which does not have a structured testing program. Using a multisite clinical data repository, we identified adult patients' first prescribed medications between January 2011 and December 2013 and investigated the frequency of germline and somatic pharmacogenomic testing, by the Pharmacogenomics Knowledgebase level of the US Food and Drug Administration label information. There were 268,262 medication orders for drugs with germline pharmacogenomic testing information in their drug labels. Pharmacogenomic testing was detected for 1.5% (129/8,718) of medication orders with recommended or required testing. Of the 3,817 medication orders associated with somatic pharmacogenomic testing information in their drug labels, 20% (372/1,819) of required tests were detected. The low rates of detectable pharmacogenomic testing suggest that structured testing programs are required to achieve the success of precision medicine.
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Affiliation(s)
- P C Mathias
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - N Hendrix
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA
| | - W-J Wang
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA
| | - K Keyloun
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA
| | - M Khelifi
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - P Tarczy-Hornoch
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA.,Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA.,Department of Computer Science and Engineering, University of Washington, Seattle, Washington, USA
| | - B Devine
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA.,Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA.,Department of Health Services, University of Washington, Seattle, Washington, USA
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95
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Caraballo PJ, Bielinski SJ, St. Sauver JL, Weinshilboum RM. Electronic Medical Record-Integrated Pharmacogenomics and Related Clinical Decision Support Concepts. Clin Pharmacol Ther 2017; 102:254-264. [DOI: 10.1002/cpt.707] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/28/2017] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Affiliation(s)
- PJ Caraballo
- Division of General Internal Medicine; Department of Medicine, Mayo Clinic; Rochester Minnesota USA
- Office of Information and Knowledge Management; Mayo Clinic; Rochester Minnesota USA
| | - SJ Bielinski
- Division of Epidemiology; Department of Health Sciences Research, Mayo Clinic; Rochester Minnesota USA
| | - JL St. Sauver
- Division of Epidemiology; Department of Health Sciences Research, Mayo Clinic; Rochester Minnesota USA
- Center for the Science of Health Care Delivery; Mayo Clinic; Rochester Minnesota USA
| | - RM Weinshilboum
- Division of Clinical Pharmacology; Departments of Molecular Pharmacology and Experimental Therapeutics & Medicine, Mayo Clinic; Rochester Minnesota USA
- Center for Individualized Medicine; Mayo Clinic; Rochester Minnesota USA
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96
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Preemptive Panel-Based Pharmacogenetic Testing: The Time is Now. Pharm Res 2017; 34:1551-1555. [PMID: 28466392 DOI: 10.1007/s11095-017-2163-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/06/2017] [Indexed: 01/06/2023]
Abstract
While recent discoveries have paved the way for the use of genotype-guided prescribing in some clinical environments, significant debate persists among clinicians and researchers about the optimal approach to pharmacogenetic testing in clinical practice. One crucial factor in this debate surrounds the timing and methodology of genotyping, specifically whether genotyping should be performed reactively for targeted genes when a single drug is prescribed, or preemptively using a panel-based approach prior to drug prescribing. While early clinical models that employed a preemptive approach were largely developed in academic health centers through multidisciplinary efforts, increasing examples of pharmacogenetic testing are emerging in community-based and primary care practice environments. However, educational and practice-based resources for these clinicians remain largely nonexistent. As such, there is a need for the health care system to shift its focus from debating about preemptive genotyping to developing and disseminating needed resources to equip frontline clinicians for clinical implementation of pharmacogenetics. Providing tools and guidance to support these emerging models of care will be essential to support the thoughtful, evidence-based use of pharmacogenetic information in diverse clinical practice environments. Specifically, the creation of efficient and accurate point-of-care resources, practice-based tools, and clinical models is needed, along with identification and dissemination of sustainable avenues for pharmacogenetic test reimbursement.
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97
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Lee YM, McKillip RP, Borden BA, Klammer CE, Ratain MJ, O’Donnell PH. Assessment of patient perceptions of genomic testing to inform pharmacogenomic implementation. Pharmacogenet Genomics 2017; 27:179-189. [PMID: 28267054 PMCID: PMC5478379 DOI: 10.1097/fpc.0000000000000275] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pharmacogenomics seeks to improve prescribing by reducing drug inefficacy/toxicity. However, views of patients during pharmacogenomic-guided care are largely unknown. We sought to understand the attitudes and perceptions of patients in an institutional implementation project and hypothesized that views would differ on the basis of experience with pharmacogenomic-guided care. METHODS Two focus groups were conducted - one group included patients who had previously been subjected to broad pharmacogenomic genotyping with results available to physicians (pharmacogenomic group), whereas the other had not been offered genotyping (traditional care). Five domains were explored: (i) experiences with medications/side effects, (ii) understanding of pharmacogenomics, (iii) impact of pharmacogenomics on relationships with healthcare professionals, (iv) scenarios involving pharmacogenomic-guided prescribing, and (v) responses to pharmacogenomic education materials. RESULTS Nine pharmacogenomic and 13 traditional care participants were included. Participants in both groups agreed that pharmacogenomics could inform prescribing and help identify problem prescriptions, but expressed concerns over insurance coverage and employment discrimination. Both groups diverged on who should be permitted to access pharmacogenomic results, with some preferring access only for providers with a longstanding relationship, whereas others argued for open access. Notably, traditional care participants showed greater skepticism about how results might be used. Case scenarios and tested educational materials elicited strong desires on the part of patients for physicians to engage participants when considering pharmacogenomic-based prescribing and to utilize shared decision-making. CONCLUSION Participants experiencing pharmacogenomic-guided care were more receptive toward pharmacogenomic information being used than traditional care participants. As key stakeholders in implementation, addressing patients' concerns will be important to successfully facilitate clinical dissemination.
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Affiliation(s)
- Yee Ming Lee
- Center for Personalized Therapeutics, The University of Chicago, Chicago, USA
| | - Ryan P. McKillip
- The University of Chicago Pritzker School of Medicine, Chicago, USA
| | - Brittany A. Borden
- Center for Personalized Therapeutics, The University of Chicago, Chicago, USA
| | | | - Mark J. Ratain
- Center for Personalized Therapeutics, The University of Chicago, Chicago, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, USA
- Department of Medicine, The University of Chicago, Chicago, USA
| | - Peter H. O’Donnell
- Center for Personalized Therapeutics, The University of Chicago, Chicago, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, USA
- Department of Medicine, The University of Chicago, Chicago, USA
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98
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Hizel HC. Highly personalized reports for personalized drug selection by expert systems as clinical decision support. Per Med 2017; 14:93-97. [PMID: 29754552 DOI: 10.2217/pme-2016-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- H Candan Hizel
- OPTI-THERA Inc., CHUM Pavilion R14-406 900, St-Denis street, Montreal (Quebec), H2X 0A9, Canada.,International & Interdisciplinary Association on the Pharmaceutical Life Cycle (IIAPC), Faculty of Law Montreal University C.P. 6128, Montreal (Quebec), H3C 3J7, Canada
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99
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Haga SB, Mills R, Moaddeb J, Allen LaPointe N, Cho A, Ginsburg GS. Primary care providers' use of pharmacist support for delivery of pharmacogenetic testing. Pharmacogenomics 2017; 18:359-367. [PMID: 28244812 DOI: 10.2217/pgs-2016-0177] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIM To investigate provider utilization of pharmacist support in the delivery of pharmacogenetic testing in a primary care setting. METHODS Two primary care clinics within Duke University Health System participated in the study between December 2012 and July 2013. One clinic was provided with an in-house pharmacist and the second clinic had an on-call pharmacist. RESULTS Providers in the in-house pharmacist arm consulted with the pharmacist for 13 of 15 cases, or about one of every four patients tested compared with one of every 7.5 patients in the on-call pharmacist arm. A total of 63 tests were ordered, 48 by providers in the pharmacist-in-house arm. CONCLUSION These findings suggest that the availability of an in-house pharmacist increases the likelihood of pharmacogenetic test utilization.
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Affiliation(s)
- Susanne B Haga
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA
| | - Rachel Mills
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA
| | - Jivan Moaddeb
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA
| | | | - Alex Cho
- Department of Medicine, Duke University, Durham, NC, USA
| | - Geoffrey S Ginsburg
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA
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Daneshi N, Holliday E, Hancock S, Schneider JJ, Scott RJ, Attia J, Milward EA. Prevalence of clinically actionable genotypes and medication exposure of older adults in the community. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2017; 10:17-27. [PMID: 28203101 PMCID: PMC5293498 DOI: 10.2147/pgpm.s123719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study analyzed clinically actionable pharmacogenotypes for clopidogrel, warfarin, statins, thiopurines, and tacrolimus using microarray data for 2121 participants (55–85 years) from the Australian Hunter Community Study (HCS). At least 74% of participants (95% confidence interval [CI]: 72%–76%) had strong level evidence for at least one medium- or high-risk actionable genotype that would trigger a change in standard therapy under current international recommendations. About 14% of these participants (95% CI: 12%–16%) were taking medication potentially affected by the genotype in question. Furthermore, ~2.6% of all participants with medication data (95% CI: 1.4%–3.8%) had a high-risk clinically actionable genotype for a medication to which they were exposed. This represents a considerable number of people at the population level. Although relationships between genotype and health outcomes remain contentious, pharmacogenotyping of multiple variants simultaneously may have considerable potential to improve medication safety and efficacy for older people in the community.
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Affiliation(s)
- Nilofar Daneshi
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy; Faculty of Health and Medicine, Centre for Bioinformatics, Biomarker Discovery and Information-Based Medicine, The University of Newcastle, Callaghan
| | - Elizabeth Holliday
- Clinical Research Design, IT and Statistical Support Unit, Hunter Medical Research Institute; Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, University of Newcastle
| | - Stephen Hancock
- Clinical Research Design, IT and Statistical Support Unit, Hunter Medical Research Institute; Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, University of Newcastle
| | - Jennifer J Schneider
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy; Faculty of Health and Medicine, Centre for Bioinformatics, Biomarker Discovery and Information-Based Medicine, The University of Newcastle, Callaghan
| | - Rodney J Scott
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy; Faculty of Health and Medicine, Centre for Bioinformatics, Biomarker Discovery and Information-Based Medicine, The University of Newcastle, Callaghan; Hunter Area Pathology Service, John Hunter Hospital, Newcastle, NSW, Australia
| | - John Attia
- Clinical Research Design, IT and Statistical Support Unit, Hunter Medical Research Institute; Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, University of Newcastle
| | - Elizabeth A Milward
- Faculty of Health and Medicine, School of Biomedical Sciences and Pharmacy; Faculty of Health and Medicine, Centre for Bioinformatics, Biomarker Discovery and Information-Based Medicine, The University of Newcastle, Callaghan
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