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Massmann A, Christensen KD, Van Heukelom J, Schultz A, Shaukat MHS, Hajek C, Weaver M, Green RC, Wu AC, Hickingbotham MR, Zoltick ES, Stys A, Stys TP. Clinical impact of preemptive pharmacogenomic testing on antiplatelet therapy in a real-world setting. Eur J Hum Genet 2024; 32:895-902. [PMID: 38424298 PMCID: PMC11291480 DOI: 10.1038/s41431-024-01567-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
CYP2C19 genotyping to guide antiplatelet therapy after patients develop acute coronary syndromes (ACS) or require percutaneous coronary interventions (PCIs) reduces the likelihood of major adverse cardiovascular events (MACE). Evidence about the impact of preemptive testing, where genotyping occurs while patients are healthy, is lacking. In patients initiating antiplatelet therapy for ACS or PCI, we compared medical records data from 67 patients who received CYP2C19 genotyping preemptively (results >7 days before need), against medical records data from 67 propensity score-matched patients who received early genotyping (results within 7 days of need). We also examined data from 140 patients who received late genotyping (results >7 days after need). We compared the impact of genotyping approaches on medication selections, specialty visits, MACE and bleeding events over 1 year. Patients with CYP2C19 loss-of-function alleles were less likely to be initiated on clopidogrel if they received preemptive rather than early or late genotyping (18.2%, 66.7%, and 73.2% respectively, p = 0.001). No differences were observed by genotyping approach in the number of specialty visits or likelihood of MACE or bleeding events (all p > 0.21). Preemptive genotyping had a strong impact on initial antiplatelet selection and a comparable impact on patient outcomes and healthcare utilization, compared to genotyping ordered after a need for antiplatelet therapy had been identified.
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Affiliation(s)
- Amanda Massmann
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA.
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA.
| | - Kurt D Christensen
- Broad Institute of Harvard and MIT, Cambridge, MA, 02141, USA
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, 02215, USA
| | - Joel Van Heukelom
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
| | - April Schultz
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
| | - Muhammad Hamza Saad Shaukat
- Minneapolis Heart Institute/Abbott Northwestern Hospital Institute, Minneapolis, MN, 55407, USA
- Sanford Cardiovascular Institute, Sioux Falls, SD, 57105, USA
| | - Catherine Hajek
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
- Helix OpCo, LLC, San Mateo, CA, 94401, USA
| | - Max Weaver
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
| | - Robert C Green
- Broad Institute of Harvard and MIT, Cambridge, MA, 02141, USA
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Ariadne Labs, Boston, MA, 02215, USA
| | - Ann Chen Wu
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, 02215, USA
| | - Madison R Hickingbotham
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
| | - Emilie S Zoltick
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
| | - Adam Stys
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
- Sanford Cardiovascular Institute, Sioux Falls, SD, 57105, USA
| | - Tomasz P Stys
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
- Sanford Cardiovascular Institute, Sioux Falls, SD, 57105, USA
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Alpert JS, Chen QM. Pharmacogenomics of Statins: A View from ChatGPT. Am J Med 2024; 137:187-188. [PMID: 37423432 DOI: 10.1016/j.amjmed.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Joseph S Alpert
- Department of Medicine, University of Arizona, Tucson, Editor in Chief, The American Journal of Medicine.
| | - Qin M Chen
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson
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Principi N, Petropulacos K, Esposito S. Impact of Pharmacogenomics in Clinical Practice. Pharmaceuticals (Basel) 2023; 16:1596. [PMID: 38004461 PMCID: PMC10675377 DOI: 10.3390/ph16111596] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Polymorphisms of genes encoding drug metabolizing enzymes and transporters can significantly modify pharmacokinetics, and this can be associated with significant differences in drug efficacy, safety, and tolerability. Moreover, genetic variants of some components of the immune system can explain clinically relevant drug-related adverse events. However, the implementation of drug dose individualization based on pharmacogenomics remains scarce. In this narrative review, the impact of genetic variations on the disposition, safety, and tolerability of the most commonly prescribed drugs is reported. Moreover, reasons for poor implementation of pharmacogenomics in everyday clinical settings are discussed. The literature analysis showed that knowledge of how genetic variations can modify the effectiveness, safety, and tolerability of a drug can lead to the adjustment of usually recommended drug dosages, improve effectiveness, and reduce drug-related adverse events. Despite some efforts to introduce pharmacogenomics in clinical practice, presently very few centers routinely use genetic tests as a guide for drug prescription. The education of health care professionals seems critical to keep pace with the rapidly evolving field of pharmacogenomics. Moreover, multimodal algorithms that incorporate both clinical and genetic factors in drug prescribing could significantly help in this regard. Obviously, further studies which definitively establish which genetic variations play a role in conditioning drug effectiveness and safety are needed. Many problems must be solved, but the advantages for human health fully justify all the efforts.
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Affiliation(s)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
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Oni-Orisan A, Tuteja S, Hoffecker G, Smith DM, Castrichini M, Crews KR, Murphy WA, Nguyen NHK, Huang Y, Lteif C, Friede KA, Tantisira K, Aminkeng F, Voora D, Cavallari LH, Whirl-Carrillo M, Duarte JD, Luzum JA. An Introductory Tutorial on Cardiovascular Pharmacogenetics for Healthcare Providers. Clin Pharmacol Ther 2023; 114:275-287. [PMID: 37303270 PMCID: PMC10406163 DOI: 10.1002/cpt.2957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/17/2023] [Indexed: 06/13/2023]
Abstract
Pharmacogenetics can improve clinical outcomes by reducing adverse drug effects and enhancing therapeutic efficacy for commonly used drugs that treat a wide range of cardiovascular diseases. One of the major barriers to the clinical implementation of cardiovascular pharmacogenetics is limited education on this field for current healthcare providers and students. The abundance of pharmacogenetic literature underscores its promise, but it can also be challenging to learn such a wealth of information. Moreover, current clinical recommendations for cardiovascular pharmacogenetics can be confusing because they are outdated, incomplete, or inconsistent. A myriad of misconceptions about the promise and feasibility of cardiovascular pharmacogenetics among healthcare providers also has halted clinical implementation. Therefore, the main goal of this tutorial is to provide introductory education on the use of cardiovascular pharmacogenetics in clinical practice. The target audience is any healthcare provider (or student) with patients that use or have indications for cardiovascular drugs. This tutorial is organized into the following 6 steps: (1) understand basic concepts in pharmacogenetics; (2) gain foundational knowledge of cardiovascular pharmacogenetics; (3) learn the different organizations that release cardiovascular pharmacogenetic guidelines and recommendations; (4) know the current cardiovascular drugs/drug classes to focus on clinically and the supporting evidence; (5) discuss an example patient case of cardiovascular pharmacogenetics; and (6) develop an appreciation for emerging areas in cardiovascular pharmacogenetics. Ultimately, improved education among healthcare providers on cardiovascular pharmacogenetics will lead to a greater understanding for its potential in improving outcomes for a leading cause of morbidity and mortality.
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Affiliation(s)
- Akinyemi Oni-Orisan
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Glenda Hoffecker
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - D. Max Smith
- MedStar Health, Columbia, Maryland, USA
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Matteo Castrichini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristine R. Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - William A. Murphy
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nam H. K. Nguyen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Yimei Huang
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Christelle Lteif
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kevin A. Friede
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kelan Tantisira
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Folefac Aminkeng
- Departments of Medicine and Biomedical Informatics (DBMI), Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
- Centre for Precision Health (CPH), National University Health System (NUHS), Singapore City, Singapore
| | - Deepak Voora
- Precision Medicine Program, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Center for Individualized and Genomic Medicine Research, Henry Ford Health System, Detroit, Michigan, USA
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Fahim SM, Alexander CSW, Qian J, Ngorsuraches S, Hohmann NS, Lloyd KB, Reagan A, Hart L, McCormick N, Westrick SC. Current published evidence on barriers and proposed strategies for genetic testing implementation in health care settings: A scoping review. J Am Pharm Assoc (2003) 2023; 63:998-1016. [PMID: 37119989 DOI: 10.1016/j.japh.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/20/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The slow uptake of genetic testing in routine clinical practice warrants the attention of researchers and practitioners to find effective strategies to facilitate implementation. OBJECTIVES This study aimed to identify the barriers to and strategies for pharmacogenetic testing implementation in a health care setting from published literature. METHODS A scoping review was conducted in August 2021 with an expanded literature search using Ovid MEDLINE, Web of Science, International Pharmaceutical Abstract, and Google Scholar to identify studies reporting implementation of pharmacogenetic testing in a health care setting, from a health care system's perspective. Articles were screened using DistillerSR and findings were organized using the 5 major domains of Consolidated Framework for Implementation Research (CFIR). RESULTS A total of 3536 unique articles were retrieved from the above sources, with only 253 articles retained after title and abstract screening. Upon screening the full texts, 57 articles (representing 46 unique practice sites) were found matching the inclusion criteria. We found that most reported barriers and their associated strategies to the implementation of pharmacogenetic testing surrounded 2 CFIR domains: intervention characteristics and inner settings. Factors relating to cost and reimbursement were described as major barriers in the intervention characteristics. In the same domain, another major barrier was the lack of utility studies to provide evidence for genetic testing uptake. Technical hurdles, such as integrating genetic information to medical records, were identified as an inner settings barrier. Collaborations and lessons from early implementers could be useful strategies to overcome majority of the barriers across different health care settings. Strategies proposed by the included implementation studies to overcome these barriers are summarized and can be used as guidance in future. CONCLUSION Barriers and strategies identified in this scoping review can provide implementation guidance for practice sites that are interested in implementing genetic testing.
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Sandritter T, Chevalier R, Abt R, Shakhnovich V. Pharmacogenetic Testing for the Pediatric Gastroenterologist: Actionable Drug-Gene Pairs to Know. Pharmaceuticals (Basel) 2023; 16:889. [PMID: 37375836 DOI: 10.3390/ph16060889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Gastroenterologists represent some of the earlier adopters of precision medicine through pharmacogenetic testing by embracing upfront genotyping for thiopurine S-methyltransferase nucleotide diphosphatase (TPMT) before prescribing 6-mercaptopurine or azathioprine for the treatment of inflammatory bowel disease. Over the last two decades, pharmacogenetic testing has become more readily available for other genes relevant to drug dose individualization. Common medications prescribed by gastroenterologists for conditions other than inflammatory bowel disease now have actionable guidelines, which can improve medication efficacy and safety; however, a clear understanding of how to interpret the results remains a challenge for many clinicians, precluding wide implementation of genotype-guided dosing for drugs other than 6-mercaptopurine and azathioprine. Our goal is to provide a practical tutorial on the currently available pharmacogenetic testing options and a results interpretation for drug-gene pairs important to medications commonly used in pediatric gastroenterology. We focus on evidence-based clinical guidelines published by the Clinical Pharmacogenetics Implementation Consortium (CPIC®) to highlight relevant drug-gene pairs, including proton pump inhibitors and selective serotonin reuptake inhibitors and cytochrome P450 (CYP) 2C19, ondansetron and CYP2D6, 6-mercaptopurine and TMPT and Nudix hydrolase 15 (NUDT15), and budesonide and tacrolimus and CYP3A5.
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Affiliation(s)
- Tracy Sandritter
- Division of Clinical Pharmacology/Medical Toxicology and Therapeutic Innovation, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
- Department of Pharmacy Practice, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rachel Chevalier
- Division of Gastroenterology, Children's Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rebecca Abt
- ProPharma Group, Overland Park, KS 66210, USA
| | - Valentina Shakhnovich
- Division of Clinical Pharmacology/Medical Toxicology and Therapeutic Innovation, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Kabbani D, Akika R, Wahid A, Daly AK, Cascorbi I, Zgheib NK. Pharmacogenomics in practice: a review and implementation guide. Front Pharmacol 2023; 14:1189976. [PMID: 37274118 PMCID: PMC10233068 DOI: 10.3389/fphar.2023.1189976] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
Considerable efforts have been exerted to implement Pharmacogenomics (PGx), the study of interindividual variations in DNA sequence related to drug response, into routine clinical practice. In this article, we first briefly describe PGx and its role in improving treatment outcomes. We then propose an approach to initiate clinical PGx in the hospital setting. One should first evaluate the available PGx evidence, review the most relevant drugs, and narrow down to the most actionable drug-gene pairs and related variant alleles. This is done based on data curated and evaluated by experts such as the pharmacogenomics knowledge implementation (PharmGKB) and the Clinical Pharmacogenetics Implementation Consortium (CPIC), as well as drug regulatory authorities such as the US Food and Drug Administration (FDA) and European Medicinal Agency (EMA). The next step is to differentiate reactive point of care from preemptive testing and decide on the genotyping strategy being a candidate or panel testing, each of which has its pros and cons, then work out the best way to interpret and report PGx test results with the option of integration into electronic health records and clinical decision support systems. After test authorization or testing requirements by the government or drug regulators, putting the plan into action involves several stakeholders, with the hospital leadership supporting the process and communicating with payers, the pharmacy and therapeutics committee leading the process in collaboration with the hospital laboratory and information technology department, and healthcare providers (HCPs) ordering the test, understanding the results, making the appropriate therapeutic decisions, and explaining them to the patient. We conclude by recommending some strategies to further advance the implementation of PGx in practice, such as the need to educate HCPs and patients, and to push for more tests' reimbursement. We also guide the reader to available PGx resources and examples of PGx implementation programs and initiatives.
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Affiliation(s)
- Danya Kabbani
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Reem Akika
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ahmed Wahid
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Ann K. Daly
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ingolf Cascorbi
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nathalie Khoueiry Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Bignucolo A, De Mattia E, Roncato R, Peruzzi E, Scarabel L, D’Andrea M, Sartor F, Toffoli G, Cecchin E. Ten-year experience with pharmacogenetic testing for DPYD in a national cancer center in Italy: Lessons learned on the path to implementation. Front Pharmacol 2023; 14:1199462. [PMID: 37256229 PMCID: PMC10225682 DOI: 10.3389/fphar.2023.1199462] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023] Open
Abstract
Background: Awareness about the importance of implementing DPYD pharmacogenetics in clinical practice to prevent severe side effects related to the use of fluoropyrimidines has been raised over the years. Since 2012 at the National Cancer Institute, CRO-Aviano (Italy), a diagnostic DPYD genotyping service was set up. Purpose: This study aims to describe the evolution of DPYD diagnostic activity at our center over the last 10 years as a case example of a successful introduction of pharmacogenetic testing in clinical practice. Methods: Data related to the diagnostic activity of in-and out-patients referred to our service between January 2012 and December 2022 were retrieved from the hospital database. Results: DPYD diagnostic activity at our center has greatly evolved over the years, shifting gradually from a post-toxicity to a pre-treatment approach. Development of pharmacogenetic guidelines by national and international consortia, genotyping, and IT technology evolution have impacted DPYD testing uptake in the clinics. Our participation in a large prospective implementation study (Ubiquitous Pharmacogenomics) increased health practitioners' and patients' awareness of pharmacogenetic matters and provided additional standardized infrastructures for genotyping and reporting. Nationwide test reimbursement together with recommendations by regulatory agencies in Europe and Italy in 2020 definitely changed the clinical practice guidelines of fluoropyrimidines prescription. A dramatic increase in the number of pre-treatment DPYD genotyping and in the coverage of new fluoropyrimidine prescriptions was noticed by the last year of observation (2022). Conclusion: The long path to a successful DPYD testing implementation in the clinical practice of a National Cancer Center in Italy demonstrated that the development of pharmacogenetic guidelines and genotyping infrastructure standardization as well as capillary training and education activity for all the potential stakeholders are fundamental. However, only national health politics of test reimbursement and clear recommendations by drug regulatory agencies will definitely move the field forward.
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Smith DM, Wake DT, Dunnenberger HM. Pharmacogenomic Clinical Decision Support: A Scoping Review. Clin Pharmacol Ther 2023; 113:803-815. [PMID: 35838358 DOI: 10.1002/cpt.2711] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/10/2022] [Indexed: 11/06/2022]
Abstract
Clinical decision support (CDS) is often cited as an essential part of pharmacogenomics (PGx) implementations. A multitude of strategies are available; however, it is unclear which strategies are effective and which metrics are used to quantify clinical utility. The objective of this scoping review was to aggregate previous studies into a cohesive depiction of the current state of PGx CDS implementations and identify areas for future research on PGx CDS. Articles were included if they (i) described electronic CDS tools for PGx and (ii) reported metrics related to PGx CDS. Twenty of 3,449 articles were included and provided data on PGx CDS metrics from 15 institutions, with 93% of programs located at academic medical centers. The most common tools in CDS implementations were interruptive post-test alerts. Metrics for clinical response and alert response ranged from 12-73% and 21-98%, respectively. Few data were found on changes in metrics over time and measures that drove the evolution of CDS systems. Relatively few data were available regarding support of optimal approaches for PGx CDS. Post-test alerts were the most widely studied approach, and their effectiveness varied greatly. Further research on the usability, effectiveness, and optimization of CDS tools is needed.
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Affiliation(s)
- D Max Smith
- MedStar Health, Columbia, Maryland, USA.,Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Dyson T Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
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Abstract
Antiplatelet therapy is used in the treatment of patients with acute coronary syndromes, stroke, and those undergoing percutaneous coronary intervention. Clopidogrel is the most widely used antiplatelet P2Y12 inhibitor in clinical practice. Genetic variation in CYP2C19 may influence its enzymatic activity, resulting in individuals who are carriers of loss-of-function CYP2C19 alleles and thus have reduced active clopidogrel metabolites, high on-treatment platelet reactivity, and increased ischemic risk. Prospective studies have examined the utility of CYP2C19 genetic testing to guide antiplatelet therapy, and more recently published meta-analyses suggest that pharmacogenetics represents a key treatment strategy to individualize antiplatelet therapy. Rapid genetic tests, including bedside genotyping platforms that are validated and have high reproducibility, are available to guide selection of P2Y12 inhibitors in clinical practice. The aim of this review is to provide an overview of the background and rationale for the role of a guided antiplatelet approach to enhance patient care.
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Affiliation(s)
- Matteo Castrichini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA;
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Naveen Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA;
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11
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Pasternak AL, Ward K, Irwin M, Okerberg C, Hayes D, Fritsche L, Zoellner S, Virzi J, Choe HM, Ellingrod V. Identifying the prevalence of clinically actionable drug-gene interactions in a health system biorepository to guide pharmacogenetics implementation services. Clin Transl Sci 2022; 16:292-304. [PMID: 36510710 PMCID: PMC9926071 DOI: 10.1111/cts.13449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/14/2022] [Accepted: 10/24/2022] [Indexed: 12/15/2022] Open
Abstract
Understanding patterns of drug-gene interactions (DGIs) is important for advancing the clinical implementation of pharmacogenetics (PGx) into routine practice. Prior studies have estimated the prevalence of DGIs, but few have confirmed DGIs in patients with known genotypes and prescriptions, nor have they evaluated clinician characteristics associated with DGI-prescribing. This retrospective chart review assessed prevalence of DGI, defined as a medication prescription in a patient with a PGx phenotype that has a clinical practice guideline recommendation to adjust therapy or monitor drug response, for patients enrolled in a research genetic biorepository linked to electronic health records (EHRs). The prevalence of prescriptions for medications with pharmacogenetic (PGx) guidelines, proportion of prescriptions with DGI, location of DGI prescription, and clinical service of the prescriber were evaluated descriptively. Seventy-five percent (57,058/75,337) of patients had a prescription for a medication with a PGx guideline. Up to 60% (n = 26,067/43,647) of patients had at least one DGI when considering recommendations to adjust or monitor therapy based on genotype. The majority (61%) of DGIs occurred in outpatient prescriptions. Proton pump inhibitors were the most common DGI medication for 11 of 12 clinical services. Almost 25% of patients (n = 10,706/43,647) had more than one unique DGI, and, among this group of patients, 61% had a DGI with more than one gene. These findings can inform future clinical implementation by identifying key stakeholders for initial DGI prescriptions, helping to inform workflows. The high prevalence of multigene interactions identified also support the use of panel PGx testing as an implementation strategy.
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Affiliation(s)
- Amy L. Pasternak
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn ArborMichiganUSA,Michigan MedicineUniversity of Michigan HealthAnn ArborMichiganUSA
| | - Kristen Ward
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn ArborMichiganUSA,Michigan MedicineUniversity of Michigan HealthAnn ArborMichiganUSA
| | - Madison Irwin
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn ArborMichiganUSA,Michigan MedicineUniversity of Michigan HealthAnn ArborMichiganUSA
| | - Carl Okerberg
- Michigan MedicineUniversity of Michigan HealthAnn ArborMichiganUSA
| | - David Hayes
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn ArborMichiganUSA
| | - Lars Fritsche
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Sebastian Zoellner
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Jessica Virzi
- Michigan MedicineUniversity of Michigan HealthAnn ArborMichiganUSA
| | - Hae Mi Choe
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn ArborMichiganUSA,Michigan MedicineUniversity of Michigan HealthAnn ArborMichiganUSA
| | - Vicki Ellingrod
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn ArborMichiganUSA
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12
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Hertz DL. Assessment of the Clinical Utility of Pretreatment DPYD Testing for Patients Receiving Fluoropyrimidine Chemotherapy. J Clin Oncol 2022; 40:3882-3892. [PMID: 36108264 DOI: 10.1200/jco.22.00037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Patients who carry pathogenic variants in DPYD have higher systemic fluoropyrimidine (FP) concentrations and greater risk of severe and fatal FP toxicity. Pretreatment DPYD testing and DPYD-guided FP dosing to reduce toxicity and health care costs is recommended by European clinical oncology guidelines and has been adopted across Europe, but has not been recommended or adopted in the United States. The cochairs of the National Comprehensive Cancer Network Guidelines for colon cancer treatment explained their concerns with recommending pretreatment DPYD testing, particularly the risk that reduced FP doses in DPYD carriers may reduce treatment efficacy. METHODS This special article uses previously published frameworks for assessing the clinical utility of cancer biomarker tests, including for germline indicators of toxicity risk, to assess the clinical utility of pretreatment DPYD testing, with a particular focus on the risk of reducing treatment efficacy. RESULTS There is no direct evidence of efficacy reduction, and the available indirect evidence demonstrates that DPYD-guided FP dosing results in similar systemic FP exposure and toxicity compared with standard dosing in noncarriers, and is well calibrated to the maximum tolerated dose, strongly suggesting there is minimal risk of efficacy reduction. CONCLUSION This article should serve as a call to action for clinicians and clinical guidelines committees in the United States to re-evaluate the clinical utility of pretreatment DPYD testing. If clinical utility has not been demonstrated, further dialogue is needed to clarify what additional evidence is needed and which of the available study designs, also described within this article, would be appropriate. Clinical guideline recommendations for pretreatment DPYD testing would increase clinical adoption and ensure that all patients receive maximally safe and effective FP treatment.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
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13
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Truong TM, Apfelbaum JL, Danahey K, Schierer E, Ludwig J, George D, House L, Karrison T, Shahul S, Anitescu M, Choksi A, Hartman S, Knoebel RW, van Wijk XM, Yeo KTJ, Meltzer D, Ratain MJ, O’Donnell PH. Pilot Findings of Pharmacogenomics in Perioperative Care: Initial Results From the First Phase of the ImPreSS Trial. Anesth Analg 2022; 135:929-940. [PMID: 35213469 PMCID: PMC9402808 DOI: 10.1213/ane.0000000000005951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pharmacogenomics, which offers a potential means by which to inform prescribing and avoid adverse drug reactions, has gained increasing consideration in other medical settings but has not been broadly evaluated during perioperative care. METHODS The Implementation of Pharmacogenomic Decision Support in Surgery (ImPreSS) Trial is a prospective, single-center study consisting of a prerandomization pilot and a subsequent randomized phase. We describe findings from the pilot period. Patients planning elective surgeries were genotyped with pharmacogenomic results, and decision support was made available to anesthesia providers in advance of surgery. Pharmacogenomic result access and prescribing records were analyzed. Surveys (Likert-scale) were administered to providers to understand utilization barriers. RESULTS Of eligible anesthesiology providers, 166 of 211 (79%) enrolled. A total of 71 patients underwent genotyping and surgery (median, 62 years; 55% female; average American Society of Anesthesiologists (ASA) score, 2.6; 58 inpatients and 13 ambulatories). No patients required postoperative intensive care or pain consultations. At least 1 provider accessed pharmacogenomic results before or during 41 of 71 surgeries (58%). Faculty were more likely to access results (78%) compared to house staff (41%; P = .003) and midlevel practitioners (15%) ( P < .0001). Notably, all administered intraoperative medications had favorable genomic results with the exception of succinylcholine administration to 1 patient with genomically increased risk for prolonged apnea (without adverse outcome). Considering composite prescribing in preoperative, recovery, throughout hospitalization, and at discharge, each patient was prescribed a median of 35 (range 15-83) total medications, 7 (range 1-22) of which had annotated pharmacogenomic results. Of 2371 prescribing events, 5 genomically high-risk medications were administered (all tramadol or omeprazole; with 2 of 5 pharmacogenomic results accessed), and 100 genomically cautionary mediations were administered (hydralazine, oxycodone, and pantoprazole; 61% rate of accessing results). Providers reported that although results were generally easy to access and understand, the most common reason for not considering results was because remembering to access pharmacogenomic information was not yet a part of their normal clinical workflow. CONCLUSIONS Our pilot data for result access rates suggest interest in pharmacogenomics by anesthesia providers, even if opportunities to alter prescribing in response to high-risk genotypes were infrequent. This pilot phase has also uncovered unique considerations for implementing pharmacogenomic information in the perioperative care setting, and new strategies including adding the involvement of surgery teams, targeting patients likely to need intensive care and dedicated pain care, and embedding pharmacists within rounding models will be incorporated in the follow-on randomized phase to increase engagement and likelihood of affecting prescribing decisions and clinical outcomes.
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Affiliation(s)
- Tien M. Truong
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL, USA
| | - Jeffrey L. Apfelbaum
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL, USA
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Emily Schierer
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Jenna Ludwig
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - David George
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Larry House
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Theodore Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Sajid Shahul
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Magdalena Anitescu
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Anish Choksi
- Department of Pharmacy, University of Chicago, Chicago, IL, USA
| | - Seth Hartman
- Department of Pharmacy, University of Chicago, Chicago, IL, USA
| | - Randall W. Knoebel
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Department of Pharmacy, University of Chicago, Chicago, IL, USA
| | - Xander M.R. van Wijk
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Kiang-Teck J. Yeo
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - David Meltzer
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mark J. Ratain
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL, USA
| | - Peter H. O’Donnell
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL, USA
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14
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Hayashi M, Bousman CA. Experience, Knowledge, and Perceptions of Pharmacogenomics among Pharmacists and Nurse Practitioners in Alberta Hospitals. PHARMACY 2022; 10:pharmacy10060139. [PMID: 36412815 PMCID: PMC9680290 DOI: 10.3390/pharmacy10060139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite evidence of clinical utility and the availability of prescription guidelines, pharmacogenomics (PGx) is not broadly used in institutional settings in Canada. To inform future implementation, this study aimed to identify healthcare provider knowledge, experience, and perceptions of PGx in Alberta, Canada. METHODS An online 44-item survey was distributed to pharmacists, nurse practitioners, and physicians employed or contracted with Alberta Health Services from January to May 2022. Questions included: demographics, professional history, PGx education and exposure, knowledge, and ability to use PGx, and attitudes towards, feasibility, clinical utility, education, and implementation. RESULTS Ninety-one pharmacists, 37 nurse practitioners, and 6 physicians completed the survey. Fifty-nine percent had 10 or more years of experience, and 71% practiced in urban settings. Only one-third had training in PGx, and one-quarter had used PGx. Most respondents (63%) had no knowledge of PGx resources, including the Pharmacogenomics Knowledge Base (75%), or the Clinical Pharmacogenetics Implementation Consortium guidelines (85%). While participants agreed that they understood genetic (75%) and PGx (63%) concepts, most disagreed with their ability regarding practical applications of PGx such as translating genotype to phenotype (74%) or counselling patients on results (66%). Participants agreed on the clinical utility of PGx in preventing adverse drug reactions (80%) and enhancing medication efficacy (77%), and identified oncology (62%), cardiovascular/stroke (60%), and psychiatry (56%) as therapeutic areas to consider implementation. At present, healthcare provider knowledge (87%), cost (81%), and limited guidelines/evidence (70%) are seen as the greatest barriers to implementation. CONCLUSION Alberta healthcare providers have limited training, experience, or knowledge in PGx. However, most appear to have a positive outlook regarding clinical utility, especially within oncology, cardiology, and psychiatry. More effort is required to socialize the availability and quality of evidence and guidelines for the interpretation of PGx test results, address other knowledge gaps, and improve financial limitations.
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Affiliation(s)
- Meagan Hayashi
- Pharmacy Services, Alberta Health Services, Edmonton, AB T6G 2R3, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 2R3, Canada
- Correspondence: ; Tel.: +780-906-5344
| | - Chad A. Bousman
- Departments of Medical Genetics, Psychiatry, Physiology & Pharmacology, Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
- Mathison Centre for Mental Health Research and Education, Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
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15
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O'Sullivan JW, Raghavan S, Marquez-Luna C, Luzum JA, Damrauer SM, Ashley EA, O'Donnell CJ, Willer CJ, Natarajan P. Polygenic Risk Scores for Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e93-e118. [PMID: 35862132 PMCID: PMC9847481 DOI: 10.1161/cir.0000000000001077] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Cardiovascular disease is the leading contributor to years lost due to disability or premature death among adults. Current efforts focus on risk prediction and risk factor mitigation' which have been recognized for the past half-century. However, despite advances, risk prediction remains imprecise with persistently high rates of incident cardiovascular disease. Genetic characterization has been proposed as an approach to enable earlier and potentially tailored prevention. Rare mendelian pathogenic variants predisposing to cardiometabolic conditions have long been known to contribute to disease risk in some families. However, twin and familial aggregation studies imply that diverse cardiovascular conditions are heritable in the general population. Significant technological and methodological advances since the Human Genome Project are facilitating population-based comprehensive genetic profiling at decreasing costs. Genome-wide association studies from such endeavors continue to elucidate causal mechanisms for cardiovascular diseases. Systematic cataloging for cardiovascular risk alleles also enabled the development of polygenic risk scores. Genetic profiling is becoming widespread in large-scale research, including in health care-associated biobanks, randomized controlled trials, and direct-to-consumer profiling in tens of millions of people. Thus, individuals and their physicians are increasingly presented with polygenic risk scores for cardiovascular conditions in clinical encounters. In this scientific statement, we review the contemporary science, clinical considerations, and future challenges for polygenic risk scores for cardiovascular diseases. We selected 5 cardiometabolic diseases (coronary artery disease, hypercholesterolemia, type 2 diabetes, atrial fibrillation, and venous thromboembolic disease) and response to drug therapy and offer provisional guidance to health care professionals, researchers, policymakers, and patients.
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16
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Nguyen AB, Cavallari LH, Rossi JS, Stouffer GA, Lee CR. Evaluation of race and ethnicity disparities in outcome studies of CYP2C19 genotype-guided antiplatelet therapy. Front Cardiovasc Med 2022; 9:991646. [PMID: 36082121 PMCID: PMC9445150 DOI: 10.3389/fcvm.2022.991646] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022] Open
Abstract
Dual antiplatelet therapy with a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin remains the standard of care for all patients undergoing percutaneous coronary intervention (PCI). It is well-established that patients carrying CYP2C19 no function alleles have impaired capacity to convert clopidogrel into its active metabolite and thus, are at higher risk of major adverse cardiovascular events (MACE). The metabolism and clinical effectiveness of prasugrel and ticagrelor are not affected by CYP2C19 genotype, and accumulating evidence from multiple randomized and observational studies demonstrates that CYP2C19 genotype-guided antiplatelet therapy following PCI improves clinical outcomes. However, most antiplatelet pharmacogenomic outcome studies to date have lacked racial and ethnic diversity. In this review, we will (1) summarize current guideline recommendations and clinical outcome evidence related to CYP2C19 genotype-guided antiplatelet therapy, (2) evaluate the presence of potential racial and ethnic disparities in the major outcome studies supporting current genotype-guided antiplatelet therapy recommendations, and (3) identify remaining knowledge gaps and future research directions necessary to advance implementation of this precision medicine strategy for dual antiplatelet therapy in diverse, real-world clinical settings.
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Affiliation(s)
- Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, United States
| | - Joseph S. Rossi
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - George A. Stouffer
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- *Correspondence: Craig R. Lee,
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17
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Albalwy F, McDermott JH, Newman WG, Brass A, Davies A. A blockchain-based framework to support pharmacogenetic data sharing. THE PHARMACOGENOMICS JOURNAL 2022; 22:264-275. [PMID: 35869255 DOI: 10.1038/s41397-022-00285-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 12/11/2022]
Abstract
The successful implementation of pharmacogenetics (PGx) into clinical practice requires patient genomic data to be shared between stakeholders in multiple settings. This creates a number of barriers to widespread adoption of PGx, including privacy concerns related to the storage and movement of identifiable genomic data. Informatic solutions that support secure and equitable data access for genomic data are therefore important to PGx. Here we propose a methodology that uses smart contracts implemented on a blockchain-based framework, PGxChain, to address this issue. The design requirements for PGxChain were identified through a systematic literature review, identifying technical challenges and barriers impeding the clinical implementation of pharmacogenomics. These requirements included security and privacy, accessibility, interoperability, traceability and legal compliance. A proof-of-concept implementation based on Ethereum was then developed that met the design requirements. PGxChain's performance was examined using Hyperledger Caliper for latency, throughput, and transaction success rate. The findings clearly indicate that blockchain technology offers considerable potential to advance pharmacogenetic data sharing, particularly with regard to PGx data security and privacy, large-scale accessibility of PGx data, PGx data interoperability between multiple health care providers and compliance with data-sharing laws and regulations.
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Affiliation(s)
- F Albalwy
- Department of Computer Science, Kilburn Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK. .,Department of Computer Science, College of Computer Science and Engineering, Taibah University, Madinah, Saudi Arabia. .,Division of Informatics, Imaging and Data Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - J H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,Division of Evolution Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - W G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,Division of Evolution Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - A Brass
- Department of Computer Science, Kilburn Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.,Division of Informatics, Imaging and Data Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - A Davies
- Division of Informatics, Imaging and Data Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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18
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Blazy C, Ellingrod V, Ward K. Variability Between Clinical Pharmacogenetics Implementation Consortium (CPIC®) Guidelines and a Commercial Pharmacogenetics Laboratory in Genotype to Phenotype Interpretations For Patients Utilizing Psychotropics. Front Pharmacol 2022; 13:939313. [PMID: 35814245 PMCID: PMC9263441 DOI: 10.3389/fphar.2022.939313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
Clinical practice environments without in-house pharmacogenetic testing often rely on commercial laboratories, especially in the setting of pharmacogenetic testing intended to guide psychotropic use. There are occasionally differences in phenotype assignment and medication recommendations between commercial laboratories and the Clinical Pharmacogenetics Implementation Consortium (CPIC). This may be problematic as many institutions that implement pharmacogenetics consider CPIC to be an important source of guidelines for recommended prescribing actions based on genetics, as well as a tool towards standardizing pharmacogenetics implementation. Here, we completed a retrospective chart review of our academic health system’s (Michigan Medicine) electronic health record with the goal of comparing phenotypic assignment of CYP2D6 and CYP2C19 genotypes between the commercial pharmacogenetic lab used most at our institution, and CPIC. Ultimately, we identified 205 patients with available pharmacogenetic results from this lab. The prevalence of conflicting phenotype assignment was 28.8% for CYP2D6 and 32.2% for CYP2C19 genotypes when comparing the commercial lab to CPIC guidelines. In several cases, the phenotypic assignment differences for antidepressants led to significant differences in medication recommendations when comparing the commercial lab report and CPIC guidelines. These results may also have implications for medications outside of psychiatry with recommendations for dose adjustments based on CYP2D6 or CYP2C19 metabolizing phenotype.
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Affiliation(s)
- Christopher Blazy
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, United States
| | - Vicki Ellingrod
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, United States
| | - Kristen Ward
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, United States
- Clinical Pharmacy Department, Michigan Medicine, Ann Arbor, MI, United States
- *Correspondence: Kristen Ward,
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19
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Lopez-Medina AI, Chahal CAA, Luzum JA. The genetics of drug-induced QT prolongation: evaluating the evidence for pharmacodynamic variants. Pharmacogenomics 2022; 23:543-557. [PMID: 35698903 DOI: 10.2217/pgs-2022-0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Drug-induced long QT syndrome (diLQTS) is an adverse effect of many commonly prescribed drugs, and it can increase the risk for lethal ventricular arrhythmias. Genetic variants in pharmacodynamic genes have been associated with diLQTS, but the strength of the evidence for each of those variants has not yet been evaluated. Therefore, the purpose of this review was to evaluate the strength of the evidence for pharmacodynamic genetic variants associated with diLQTS using a novel, semiquantitative scoring system modified from the approach used for congenital LQTS. KCNE1-D85N and KCNE2-T8A had definitive and strong evidence for diLQTS, respectively. The high level of evidence for these variants supports current consideration as risk factors for patients that will be prescribed a QT-prolonging drug.
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Affiliation(s)
- Ana I Lopez-Medina
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - Choudhary Anwar A Chahal
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.,Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,WellSpan Health, Lancaster, PA 17607, USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
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20
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Khan AR, Shah SH, Ajaz S, Firasat S, Abid A, Raza A. The Prevalence of Pharmacogenomics Variants and Their Clinical Relevance Among the Pakistani Population. Evol Bioinform Online 2022; 18:11769343221095834. [PMID: 35497687 PMCID: PMC9047794 DOI: 10.1177/11769343221095834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Pharmacogenomics (PGx), forming the basis of precision medicine, has
revolutionized traditional medical practice. Currently, drug responses such
as drug efficacy, drug dosage, and drug adverse reactions can be anticipated
based on the genetic makeup of the patients. The pharmacogenomic data of
Pakistani populations are limited. This study investigates the frequencies
of pharmacogenetic variants and their clinical relevance among ethnic groups
in Pakistan. Methods: The Pharmacogenomics Knowledge Base (PharmGKB) database was used to extract
pharmacogenetic variants that are involved in medical conditions with high
(1A + 1B) to moderate (2A + 2B) clinical evidence. Subsequently, the allele
frequencies of these variants were searched among multiethnic groups of
Pakistan (Balochi, Brahui, Burusho, Hazara, Kalash, Pashtun, Punjabi, and
Sindhi) using the 1000 Genomes Project (1KGP) and
ALlele FREquency
Database (ALFRED). Furthermore, the published
Pharmacogenomics literature on the Pakistani population was reviewed in
PubMed and Google Scholar. Results: Our search retrieved (n = 29) pharmacogenetic genes and their (n = 44)
variants with high to moderate evidence of clinical association. These
pharmacogenetic variants correspond to drug-metabolizing enzymes (n = 22),
drug-metabolizing transporters (n = 8), and PGx gene regulators, etc.
(n = 14). We found 5 pharmacogenetic variants present at >50% among 8
ethnic groups of Pakistan. These pharmacogenetic variants include
CYP2B6 (rs2279345, C; 70%-86%), CYP3A5
(rs776746, C; 64%-88%), FLT3 (rs1933437, T; 54%-74%),
CETP (rs1532624, A; 50%-70%), and DPP6
(rs6977820, C; 61%-86%) genes that are involved in drug response for
acquired immune deficiency syndrome, transplantation, cancer, heart disease,
and mental health therapy, respectively. Conclusions: This study highlights the frequency of important clinical pharmacogenetic
variants (1A, 1B, 2A, and 2B) among multi-ethnic Pakistani populations. The
high prevalence (>50%) of single nucleotide pharmacogenetic variants may
contribute to the drug response/diseases outcome. These PGx data could be
used as pharmacogenetic markers in the selection of appropriate therapeutic
regimens for specific ethnic groups of Pakistan.
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Affiliation(s)
- Abdul Rafay Khan
- Center for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Sayed Hajan Shah
- Center for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Sadia Ajaz
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Sadaf Firasat
- Center for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Aiysha Abid
- Center for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ali Raza
- Center for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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21
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Beitelshees AL, Thomas CD, Empey PE, Stouffer GA, Angiolillo DJ, Franchi F, Tuteja S, Limdi NA, Lee JC, Duarte JD, Kreutz RP, Skaar TC, Coons JC, Giri J, McDonough CW, Rowland R, Stevenson JM, Thai T, Vesely MR, Wellen JT, Johnson JA, Winterstein AG, Cavallari LH, Lee CR. CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention in Diverse Clinical Settings. J Am Heart Assoc 2022; 11:e024159. [PMID: 35156424 PMCID: PMC9245803 DOI: 10.1161/jaha.121.024159] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Studies have demonstrated increased risk of major atherothrombotic events in CYP2C19 loss-of-function (LOF) variant carriers versus non-carriers treated with clopidogrel after percutaneous coronary intervention (PCI). We sought to evaluate real-world outcomes with the clinical implementation of CYP2C19-guided antiplatelet therapy after PCI. Methods and Results Data from 9 medical centers where genotyping was performed in the setting of PCI were included. Alternative therapy with prasugrel or ticagrelor was recommended for patients with a CYP2C19 LOF variant. The primary outcome was the composite of major atherothrombotic events (all-cause death, myocardial infarction, ischemic stroke, stent thrombosis, or hospitalization for unstable angina) within 12 months following PCI. Moderate or severe/life-threatening bleeding within 12 months was a secondary outcome. Among 3342 patients, 1032 (31%) were LOF carriers, of whom 571/1032 (55%) were treated with alternative therapy. In LOF carriers, the rate of major atherothrombotic events was lower in patients treated with alternative therapy versus clopidogrel (adjusted HR, 0.56; 95% CI 0.39-0.82). In those without a LOF allele, no difference was observed (adjusted HR, 1.07; 95% CI 0.71-1.60). There was no difference in bleeding with alternative therapy versus clopidogrel in either LOF carriers or those without a LOF allele. Conclusions Real-world data demonstrate lower atherothrombotic risk in CYP2C19 LOF carriers treated with alternative therapy versus clopidogrel and similar risk in those without a LOF allele treated with clopidogrel or alternative therapy. These data suggest that PCI patients treated with clopidogrel should undergo genotyping so that CYP2C19 LOF carriers can be identified and treated with alternative therapy.
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Affiliation(s)
- Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Philip E. Empey
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC
| | | | - Francesco Franchi
- University of Florida College of Medicine‐JacksonvilleJacksonvilleFL
| | - Sony Tuteja
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Nita A. Limdi
- Department of NeurologyProgram for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine InstituteSchool of MedicineUniversity of Alabama at BirminghamAL
| | - James C. Lee
- Department of Pharmacy PracticeUniversity of Illinois at ChicagoIL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | | | | | - James C. Coons
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - Jay Giri
- Cardiovascular Medicine DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Rachel Rowland
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - James M. Stevenson
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA,Division of Clinical PharmacologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Thuy Thai
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Jacob T. Wellen
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Craig R. Lee
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC,Division of Pharmacotherapy and Experimental TherapeuticsUNC Eshelman School of PharmacyUniversity of North Carolina at Chapel HillNC
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22
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Ratner L, Zhu J‘D, Gower MN, Patel T, Miller JA, Cipriani A, Stouffer GA, Crona DJ, Lee CR. Pharmacogenomic prescribing opportunities in percutaneous coronary intervention and bone marrow transplant patients. Pharmacogenomics 2022; 23:183-194. [PMID: 35083934 PMCID: PMC8914581 DOI: 10.2217/pgs-2021-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aim: To evaluate the potential impact of preemptive multigene pharmacogenomic (PGx) testing on medication prescribing in real-world clinical settings. Patients & methods: Prescription frequencies for 65 medications with actionable PGx recommendations were collected in 215 percutaneous coronary intervention (PCI) and 131 allogeneic hematopoietic cell transplant (allo-HCT) patients. A simulation projected the number of PGx-guided prescribing opportunities. Results: In PCI and allo-HCT patients, respectively, 66.5 and 90.1% were prescribed at least one medication with actionable PGx prescribing recommendations. Simulations projected 26.5 and 41.2 total PGx-guided prescribing opportunities per 100 PCI and allo-HCT patients, respectively, if multigene PGx results were available. Conclusion: A multigene PGx testing strategy offers potential to optimize medication prescribing beyond clopidogrel and tacrolimus in PCI and allo-HCT patients.
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Affiliation(s)
- Lindsay Ratner
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Jing ‘Daisy’ Zhu
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Megan N Gower
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Tejendra Patel
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Jordan A Miller
- Department of Pharmacy, University of North Carolina Hospitals & Clinics, Chapel Hill, NC, USA
| | - Amber Cipriani
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA,Department of Pharmacy, University of North Carolina Hospitals & Clinics, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology, UNC School of Medicine, University of North Carolina, Chapel Hill, NC, USA,McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Daniel J Crona
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA,Department of Pharmacy, University of North Carolina Hospitals & Clinics, Chapel Hill, NC, USA,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Craig R Lee
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA,Division of Cardiology, UNC School of Medicine, University of North Carolina, Chapel Hill, NC, USA,McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA,Author for correspondence: Tel.: +1 919 843 7673;
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23
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Shugg T, Pasternak AL, Luzum JA. Comparison of clinical pharmacogenetic recommendations across therapeutic areas. Pharmacogenet Genomics 2022; 32:51-59. [PMID: 34412102 PMCID: PMC8702450 DOI: 10.1097/fpc.0000000000000452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Evaluations from pharmacogenetics implementation programs at major US medical centers have reported variability in the clinical adoption of pharmacogenetics across therapeutic areas. A potential cause for this variability may involve therapeutic area-specific differences in published pharmacogenetics recommendations to clinicians. To date, however, the potential for differences in clinical pharmacogenetics recommendations by therapeutic areas from prominent US guidance sources has not been assessed. Accordingly, our objective was to comprehensively compare essential elements from clinical pharmacogenetics recommendations contained within Clinical Pharmacogenetics Implementation Consortium guidelines, US Food and Drug Administration drug labels and clinical practice guidelines from US professional medical organizations across therapeutic areas. METHODS We analyzed clinical pharmacogenetics recommendation elements within Clinical Pharmacogenetics Implementation Consortium guidelines, US Food and Drug Administration drug labels and professional clinical practice guidelines through 05/24/19. RESULTS We identified 606 unique clinical pharmacogenetics recommendations, with the most recommendations involving oncology (217 recommendations), hematology (79), psychiatry (65), cardiovascular (43) and anesthetic (37) medications. Within our analyses, we observed considerable variability across therapeutic areas within the following essential pharmacogenetics recommendation elements: the recommended clinical management strategy; the relevant genetic biomarkers; the organizations providing pharmacogenetics recommendations; whether routine genetic screening was recommended; and the time since recommendations were published. CONCLUSIONS On the basis of our results, we infer that observed differences in clinical pharmacogenetics recommendations across therapeutic areas may result from specific factors associated with individual disease states, the associated genetic biomarkers, and the characteristics of the organizations providing recommendations.
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Affiliation(s)
- Tyler Shugg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Amy L. Pasternak
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
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24
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Grande KJ, Dalton R, Moyer NA, Arwood MJ, Nguyen KA, Sumfest J, Ashcraft KC, Cooper-DeHoff RM. Assessment of a Manual Method versus an Automated, Probability-Based Algorithm to Identify Patients at High Risk for Pharmacogenomic Adverse Drug Outcomes in a University-Based Health Insurance Program. J Pers Med 2022; 12:jpm12020161. [PMID: 35207649 PMCID: PMC8878761 DOI: 10.3390/jpm12020161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 12/21/2022] Open
Abstract
We compared patient cohorts selected for pharmacogenomic testing using a manual method or automated algorithm in a university-based health insurance network. The medication list was compiled from claims data during 4th quarter 2018. The manual method selected patients by number of medications by the health system’s list of medications for pharmacogenomic testing. The automated method used YouScript’s pharmacogenetic interaction probability (PIP) algorithm to select patients based on the probability that testing would result in detection of one or more clinically significant pharmacogenetic interactions. A total of 6916 patients were included. Patient cohorts selected by each method differed substantially, including size (manual n = 218, automated n = 286) and overlap (n = 41). The automated method was over twice as likely to identify patients where testing may reveal a clinically significant pharmacogenetic interaction than the manual method (62% vs. 29%, p < 0.0001). The manual method captured more patients with significant drug–drug or multi-drug interactions (80.3% vs. 40.2%, respectively, p < 0.0001), higher average number of significant drug interactions per patient (3.3 vs. 1.1, p < 0.0001), and higher average number of unique medications per patient (9.8 vs. 7.4, p < 0.0001). It is possible to identify a cohort of patients who would likely benefit from pharmacogenomic testing using manual or automated methods.
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Affiliation(s)
| | - Rachel Dalton
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (R.D.); (K.A.N.)
| | | | | | - Khoa A. Nguyen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (R.D.); (K.A.N.)
| | - Jill Sumfest
- GatorCare, University of Florida, Gainesville, FL 32610, USA;
| | | | - Rhonda M. Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (R.D.); (K.A.N.)
- Division of Cardiology, College of Medicine, University of Florida, Gainesville, FL 32610, USA
- Correspondence: ; Tel.: +1-352-359-2658
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25
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Mroz P, Michel S, Allen JD, Meyer T, McGonagle EJ, Carpentier R, Vecchia A, Schlichte A, Bishop JR, Dunnenberger HM, Yohe S, Thyagarajan B, Jacobson PA, Johnson SG. Development and Implementation of In-House Pharmacogenomic Testing Program at a Major Academic Health System. Front Genet 2021; 12:712602. [PMID: 34745204 PMCID: PMC8564018 DOI: 10.3389/fgene.2021.712602] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/16/2021] [Indexed: 12/26/2022] Open
Abstract
Pharmacogenomics (PGx) studies how a person's genes affect the response to medications and is quickly becoming a significant part of precision medicine. The clinical application of PGx principles has consistently been cited as a major opportunity for improving therapeutic outcomes. Several recent studies have demonstrated that most individuals (> 90%) harbor PGx variants that would be clinically actionable if prescribed a medication relevant to that gene. In multiple well-conducted studies, the results of PGx testing have been shown to guide therapy choice and dosing modifications which improve treatment efficacy and reduce the incidence of adverse drug reactions (ADRs). Although the value of PGx testing is evident, its successful implementation in a clinical setting presents a number of challenges to molecular diagnostic laboratories, healthcare systems, providers and patients. Different molecular methods can be applied to identify PGx variants and the design of the assay is therefore extremely important. Once the genotyping results are available the biggest technical challenge lies in turning this complex genetic information into phenotypes and actionable recommendations that a busy clinician can effectively utilize to provide better medical care, in a cost-effective, efficient and reliable manner. In this paper we describe a successful and highly collaborative implementation of the PGx testing program at the University of Minnesota and MHealth Fairview Molecular Diagnostic Laboratory and selected Pharmacies and Clinics. We offer detailed descriptions of the necessary components of the pharmacogenomic testing implementation, the development and technical validation of the in-house SNP based multiplex PCR based assay targeting 20 genes and 48 SNPs as well as a separate CYP2D6 copy number assay along with the process of PGx report design, results of the provider and pharmacists usability studies, and the development of the software tool for genotype-phenotype translation and gene-phenotype-drug CPIC-based recommendations. Finally, we outline the process of developing the clinical workflow that connects the providers with the PGx experts within the Molecular Diagnostic Laboratory and the Pharmacy.
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Affiliation(s)
- Pawel Mroz
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Stephen Michel
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Josiah D Allen
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Tim Meyer
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Erin J McGonagle
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | | | | | | | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Henry M Dunnenberger
- Mark R Neaman Center for Personalized Medicine Center, NorthShore University HealthSystem, Evanston, IL, United States
| | - Sophia Yohe
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Bharat Thyagarajan
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Steven G Johnson
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
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26
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Clinical implementation of drug metabolizing gene-based therapeutic interventions worldwide. Hum Genet 2021; 141:1137-1157. [PMID: 34599365 DOI: 10.1007/s00439-021-02369-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/09/2021] [Indexed: 02/05/2023]
Abstract
Over the last few years, the field of pharmacogenomics has gained considerable momentum. The advances of new genomics and bioinformatics technologies propelled pharmacogenomics towards its implementation in the clinical setting. Since 2007, and especially the last-5 years, many studies have focused on the clinical implementation of pharmacogenomics while identifying obstacles and proposed strategies and approaches for overcoming them in the real world of primary care as well as outpatients and inpatients clinics. Here, we outline the recent pharmacogenomics clinical implementation projects and provide details of the study designs, including the most predominant and innovative, as well as clinical studies worldwide that focus on outpatients and inpatient clinics, and primary care. According to these studies, pharmacogenomics holds promise for improving patients' health in terms of efficacy and toxicity, as well as in their overall quality of life, while simultaneously can contribute to the minimization of healthcare expenditure.
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27
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Limkakeng AT, Manandhar P, Erkanli A, Eucker SA, Root A, Voora D. United States Emergency Department Use of Medications with Pharmacogenetic Recommendations. West J Emerg Med 2021; 22:1347-1354. [PMID: 34787561 PMCID: PMC8597689 DOI: 10.5811/westjem.2021.5.51248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/17/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Emergency departments (ED) use many medications with a range of therapeutic efficacy and potential significant side effects, and many medications have dosage adjustment recommendations based on the patient’s specific genotype. How frequently medications with such pharmaco-genetic recommendations are used in United States (US) EDs has not been studied. Methods We conducted a cross-sectional analysis of the 2010–2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). We reported the proportion of ED visits in which at least one medication with Clinical Pharmacogenetics Implementation Consortium (CPIC) recommendation of Level A or B evidence was ordered. Secondary comparisons included distributions and 95% confidence intervals of age, gender, race/ethnicity, ED disposition, geographical region, immediacy, and insurance status between all ED visits and those involving a CPIC medication. Results From 165,155 entries representing 805,726,000 US ED visits in the 2010–2015 NHAMCS, 148,243,000 ED visits (18.4%) led to orders of CPIC medications. The most common CPIC medication was tramadol (6.3%). Visits involving CPIC medications had higher proportions of patients who were female, had private insurance and self-pay, and were discharged from the ED. They also involved lower proportions of patients with Medicare and Medicaid. Conclusion Almost one fifth of US ED visits involve a medication with a pharmacogenetic recommendation that may impact the efficacy and toxicity for individual patients. While direct application of genotyping is still in development, it is important for emergency care providers to understand and support this technology given its potential to improve individualized, patient-centered care.
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Affiliation(s)
- Alexander T Limkakeng
- Duke University School of Medicine, Division of Emergency Medicine, Durham, North Carolina
| | - Pratik Manandhar
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Alaatin Erkanli
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Stephanie A Eucker
- Duke University School of Medicine, Division of Emergency Medicine, Durham, North Carolina.,Duke University School of Medicine, Department of Orthopedics, Durham, North Carolina
| | - Adam Root
- Duke University Hospital, Department of Pharmacy, Durham, North Carolina
| | - Deepak Voora
- Duke University School of Medicine, Division of Cardiology, Durham, North Carolina
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28
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Membrive Jiménez C, Pérez Ramírez C, Sánchez Martín A, Vieira Maroun S, Arias Santiago S, Ramírez Tortosa MC, Jiménez Morales A. Clinical Application of Pharmacogenetic Markers in the Treatment of Dermatologic Pathologies. Pharmaceuticals (Basel) 2021; 14:ph14090905. [PMID: 34577605 PMCID: PMC8471650 DOI: 10.3390/ph14090905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 02/07/2023] Open
Abstract
Dermatologic pathologies are the fourth most common cause of non-fatal disease worldwide; however, they produce a psychosocial, economic, and occupational impact equal to or greater than other chronic conditions. The most prevalent are actinic keratosis, followed by basal-cell carcinoma, in a lesser proportion acne vulgaris, psoriasis, and hidradenitis suppurativa, among others, and more rarely dermatitis herpetiformis. To treat actinic keratosis and basal-cell carcinoma, 5-fluorouracil (5-FU) 0.5% is administered topically with good results, although in certain patients it produces severe toxicity. On the other hand, dapsone is a drug commonly used in inflammatory skin conditions such as dermatitis herpetiformis; however, it occasionally causes hemolytic anemia. Additionally, biologic drugs indicated for the treatment of moderate-to-severe psoriasis and hidradenitis suppurativa have proved to be effective and safe; nevertheless, a small percentage of patients do not respond to treatment with biologics in the long term or they are ineffective. This interindividual variability in response may be due to alterations in genes that encode proteins involved in the pathologic environment of the disease or the mechanism of action of the medication. Pharmacogenetics studies the relationship between genetic variations and drug response, which is useful for the early identification of non-responsive patients and those with a higher risk of developing toxicity upon treatment. This review describes the pharmacogenetic recommendations with the strongest evidence at present for the treatments used in dermatology, highlighting those included in clinical practice guides. Currently, we could only find pharmacogenetic clinical guidelines for 5-FU. However, the summary of product characteristics for dapsone contains a pharmacogenetic recommendation from the United States Food and Drug Administration. Finally, there is an enormous amount of information from pharmacogenetic studies in patients with dermatologic pathologies (mainly psoriasis) treated with biologic therapies, but they need to be validated in order to be included in clinical practice guides.
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Affiliation(s)
- Cristina Membrive Jiménez
- Pharmacy Service, Pharmacogenetics Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain; (C.M.J.); (A.S.M.); (S.V.M.); (A.J.M.)
| | - Cristina Pérez Ramírez
- Pharmacy Service, Pharmacogenetics Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain; (C.M.J.); (A.S.M.); (S.V.M.); (A.J.M.)
- Center of Biomedical Research, Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Avda. del Conocimiento s/n., Armilla, 18016 Granada, Spain;
- Correspondence:
| | - Almudena Sánchez Martín
- Pharmacy Service, Pharmacogenetics Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain; (C.M.J.); (A.S.M.); (S.V.M.); (A.J.M.)
| | - Sayleth Vieira Maroun
- Pharmacy Service, Pharmacogenetics Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain; (C.M.J.); (A.S.M.); (S.V.M.); (A.J.M.)
| | | | - María Carmen Ramírez Tortosa
- Center of Biomedical Research, Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Avda. del Conocimiento s/n., Armilla, 18016 Granada, Spain;
| | - Alberto Jiménez Morales
- Pharmacy Service, Pharmacogenetics Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain; (C.M.J.); (A.S.M.); (S.V.M.); (A.J.M.)
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29
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Meaddough EL, Sarasua SM, Fasolino TK, Farrell CL. The impact of pharmacogenetic testing in patients exposed to polypharmacy: a scoping review. THE PHARMACOGENOMICS JOURNAL 2021; 21:409-422. [PMID: 34140647 DOI: 10.1038/s41397-021-00224-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 01/31/2023]
Abstract
Polypharmacy poses a significant risk for adverse reactions. While there are clinical decision support tools to assist clinicians in medication management, pharmacogenetic testing to identify potential drug-gene or drug-drug-gene interactions is not widely implemented in the clinical setting. A PRISMA-compliant scoping review was performed to determine if pharmacogenetic testing for absorption, distribution, metabolism, and excretion (ADME)-related genetic variants is associated with improved clinical outcomes in patients with polypharmacy. Six studies were reviewed. Five reported improved clinical outcomes, reduced side effects, reduction in the number of drugs used, or reduced healthcare utilization. The reviewed studies varied in methodological quality, risk of bias, and outcome measures. Age, diet, disease state, and treatment adherence also influence drug response, and may confound the relationship between genetic polymorphisms and treatment outcomes. Further studies using a randomized control design are needed. We conclude that pharmacogenetic testing represents an opportunity to improve health outcomes in patients exposed to polypharmacy, particularly in patients with psychiatric disorders and the elderly.
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Affiliation(s)
- Erika L Meaddough
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, SC, USA.
| | - Sara M Sarasua
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, SC, USA
| | - Tracy K Fasolino
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, SC, USA
| | - Christopher L Farrell
- School of Nursing, Healthcare Genetics Program, Clemson University, Clemson, SC, USA.,Department of Pharmaceutical & Administrative Sciences, Presbyterian College School of Pharmacy, Clinton, SC, USA
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30
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Scott SA, Nicoletti P. Novel Pharmacogenomic Locus Implicated in Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. J Am Coll Cardiol 2021; 78:710-712. [PMID: 34384553 DOI: 10.1016/j.jacc.2021.05.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Stuart A Scott
- Department of Pathology, Stanford University, Stanford, California, USA; Stanford Medicine Clinical Genomics Laboratory, Stanford Health Care, Palo Alto, California, USA.
| | - Paola Nicoletti
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Sema4, Stamford, Connecticut, USA
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31
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Jafrin S, Naznin NE, Reza MS, Aziz MA, Islam MS. Risk of stroke in CYP2C19 LoF polymorphism carrier coronary artery disease patients undergoing clopidogrel therapy: An ethnicity-based updated meta-analysis. Eur J Intern Med 2021; 90:49-65. [PMID: 34092486 DOI: 10.1016/j.ejim.2021.05.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/20/2021] [Accepted: 05/16/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antiplatelet agent clopidogrel has been widely used for stroke management for many years, although resistance to clopidogrel may increase the chance of stroke recurrence. CYP2C19 loss-of-function (LoF) polymorphism is assumed to be responsible for the poor metabolism of clopidogrel that ultimately turns to resistance. Previous publications could not provide firm evidence due to highly conflicting and heterogeneous outcomes. AIM To get clear evidence from an updated meta-analysis on CYP2C19 LoF polymorphism association with stroke risk in clopidogrel treated patients, this study has been performed. METHODS We conducted a meta-analysis with 72 selected studies from authentic databases, including 40,035 coronary artery disease patients treated with clopidogrel. RESULTS This analysis showed that the worldwide carrier of one or more CYP2C19 LoF alleles had a significantly higher risk of stroke and composite events than the non-LoF carriers (RR=1.78, 95% CI=1.52-2.07, p<0.00001 and RR=1.39, 95% CI=1.26-1.54, p<0.00001, respectively). Besides, subgroup analysis showed that Asian CYP2C19 LoF carriers had a significantly increased risk of stroke (RR=1.91, 95% CI=1.60-2.28, p<0.00001) while the risk of composite events was significantly higher in all ethnic populations (Asian: RR=1.58, 95% CI=1.32-1.89, p<0.00001; Caucasian: RR=1.27, 95% CI=1.08-1.50, p=0.003; Hispanic and others: RR=1.21, 95% CI=1.09-1.34, p=0.0003). CONCLUSION Our meta-analysis confirmed that the presence of CYP2C19 LoF alleles increases the risk of stroke and composite events recurrence in the worldwide population, especially in Asians undergoing clopidogrel treatment. Alternative antiplatelet therapy should be investigated thoroughly for the intermediate and poor metabolizers.
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Affiliation(s)
- Sarah Jafrin
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Nura Ershad Naznin
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Md Sharif Reza
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Md Abdul Aziz
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Mohammad Safiqul Islam
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh.
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32
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David V, Fylan B, Bryant E, Smith H, Sagoo GS, Rattray M. An Analysis of Pharmacogenomic-Guided Pathways and Their Effect on Medication Changes and Hospital Admissions: A Systematic Review and Meta-Analysis. Front Genet 2021; 12:698148. [PMID: 34394187 PMCID: PMC8362615 DOI: 10.3389/fgene.2021.698148] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/28/2021] [Indexed: 01/02/2023] Open
Abstract
Ninety-five percent of the population are estimated to carry at least one genetic variant that is discordant with at least one medication. Pharmacogenomic (PGx) testing has the potential to identify patients with genetic variants that puts them at risk of adverse drug reactions and sub-optimal therapy. Predicting a patient's response to medications could support the safe management of medications and reduce hospitalization. These benefits can only be realized if prescribing clinicians make the medication changes prompted by PGx test results. This review examines the current evidence on the impact PGx testing has on hospital admissions and whether it prompts medication changes. A systematic search was performed in three databases (Medline, CINAHL and EMBASE) to search all the relevant studies published up to the year 2020, comparing hospitalization rates and medication changes amongst PGx tested patients with patients receiving treatment-as-usual (TAU). Data extracted from full texts were narratively synthesized using a process model developed from the included studies, to derive themes associated to a suggested workflow for PGx-guided care and its expected benefit for medications optimization and hospitalization. A meta-analysis was undertaken on all the studies that report the number of PGx tested patients that had medication change(s) and the number of PGx tested patients that were hospitalized, compared to participants that received TAU. The search strategy identified 5 hospitalization themed studies and 5 medication change themed studies for analysis. The meta-analysis showed that medication changes occurred significantly more frequently in the PGx tested arm across 4 of 5 studies. Meta-analysis showed that all-cause hospitalization occurred significantly less frequently in the PGx tested arm than the TAU. The results show proof of concept for the use of PGx in prescribing that produces patient benefit. However, the review also highlights the opportunities and evidence gaps that are important when considering the introduction of PGx into health systems; namely patient involvement in PGx prescribing decisions, thus a better understanding of the perspective of patients and prescribers. We highlight the opportunities and evidence gaps that are important when considering the introduction of PGx into health systems.
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Affiliation(s)
- Victoria David
- Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom.,School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom.,Wolfson Centre for Applied Health Research, Bradford, United Kingdom
| | - Beth Fylan
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom.,Wolfson Centre for Applied Health Research, Bradford, United Kingdom.,Yorkshire and Humber Patient Safety Translational Research Centre, Bradford Institute of Health Research, Bradford, United Kingdom
| | - Eleanor Bryant
- Wolfson Centre for Applied Health Research, Bradford, United Kingdom.,Division of Psychology in the School of Social Sciences, University of Bradford, Bradford, United Kingdom
| | - Heather Smith
- Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
| | - Gurdeep S Sagoo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds In Vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Marcus Rattray
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom.,Wolfson Centre for Applied Health Research, Bradford, United Kingdom
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33
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McDonough CW. Pharmacogenomics in Cardiovascular Diseases. Curr Protoc 2021; 1:e189. [PMID: 34232575 DOI: 10.1002/cpz1.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiovascular pharmacogenomics is the study and identification of genomic markers that are associated with variability in cardiovascular drug response, cardiovascular drug-related outcomes, or cardiovascular drug-related adverse events. This overview presents an introduction and historical background to cardiovascular pharmacogenomics, and a protocol for designing a cardiovascular pharmacogenomics study. Important considerations are also included for constructing a cardiovascular pharmacogenomics phenotype, designing the replication or validation strategy, common statistical approaches, and how to put the results in context with the cardiovascular drug or cardiovascular disease under investigation. © 2021 Wiley Periodicals LLC. Basic Protocol: Designing a cardiovascular pharmacogenomics study.
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Affiliation(s)
- Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
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34
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Hertz DL, Arwood MJ, Stocco G, Singh S, Karnes JH, Ramsey LB. Planning and Conducting a Pharmacogenetics Association Study. Clin Pharmacol Ther 2021; 110:688-701. [PMID: 33880756 DOI: 10.1002/cpt.2270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/04/2021] [Indexed: 12/13/2022]
Abstract
Pharmacogenetics (PGx) association studies are used to discover, replicate, and validate the association between an inherited genotype and a treatment outcome. The objective of this tutorial is to provide trainees and novice PGx researchers with an overview of the major decisions that need to be made when designing and conducting a PGx association study. The first critical decision is to determine whether the objective of the study is discovery, replication, or validation. Next, the researcher must identify a patient cohort that has all of the data necessary to conduct the intended analysis. Then, the investigator must select and define the treatment outcome, or phenotype, that will be analyzed. Next, the investigator must determine what genotyping approach and genetic data will be included in the analysis. Finally, the association between the genotype and phenotype is tested using some statistical analysis methodology. This tutorial is divided into five sections; each section describes commonly used approaches and provides suggestions and resources for designing and conducting a PGx association study. Successful PGx association studies are necessary to discover and validate associations between inherited genetic variation and treatment outcomes, which enable clinical translation to improve efficacy and reduce toxicity of treatment.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Meghan J Arwood
- Tabula Rasa HealthCare, Precision Pharmacotherapy Research and Development Institute, Orlando, Florida, USA
| | - Gabriele Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Sonal Singh
- Takeda California, San Diego, California, USA
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura B Ramsey
- Divisions of Clinical Pharmacology & Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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35
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Luzum JA, Petry N, Taylor AK, Van Driest SL, Dunnenberger HM, Cavallari LH. Moving Pharmacogenetics Into Practice: It's All About the Evidence! Clin Pharmacol Ther 2021; 110:649-661. [PMID: 34101169 DOI: 10.1002/cpt.2327] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022]
Abstract
The evidence for pharmacogenetics has grown rapidly in recent decades. However, the strength of evidence required for the clinical implementation of pharmacogenetics is highly debated. Therefore, the purpose of this review is to summarize different perspectives on the evidence required for the clinical implementation of pharmacogenetics. First, we present two patient cases that demonstrate how knowledge of pharmacogenetic evidence affected their care. Then we summarize resources that curate pharmacogenetic evidence, types of evidence (with an emphasis on randomized controlled trials [RCT]) and their limitations, and different perspectives from implementers, clinicians, and patients. We compare pharmacogenetics to a historical example (i.e., the evidence required for the clinical implementation of pharmacokinetics/therapeutic drug monitoring), and we provide future perspectives on the evidence for pharmacogenetic panels and the need for more education in addition to evidence. Although there are differences in the interpretation of pharmacogenetic evidence across resources, efforts for standardization are underway. Survey data illustrate the value of pharmacogenetic testing from the patient perspective, with their providers seen as key to ensuring maximum benefit from test results. However, clinicians and practice guidelines from medical societies often rely on RCT data to guide treatment decisions, which are not always feasible or ethical in pharmacogenetics. Thus, recognition of other types of evidence to support pharmacogenetic implementation is needed. Among pharmacogenetic implementers, consistent evidence of pharmacogenetic associations is deemed most critical. Ultimately, moving pharmacogenetics into practice will require consideration of multiple stakeholder perspectives, keeping particularly attuned to the voice of the ultimate stakeholder-the patient.
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Affiliation(s)
- Jasmine A Luzum
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Natasha Petry
- Department of Pharmacy Practice, College of Health Professions, North Dakota State University, Fargo, North Dakota, USA.,Sanford Imagenetics, Sioux Falls, South Dakota, USA
| | - Annette K Taylor
- Colorado Coagulation, Laboratory Corporation of America Holdings, Englewood, Colorado, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Tillman EM, Beavers CJ, Afanasjeva J, Momary KM, Strnad KG, Yerramilli A, Williams AM, Smith BA, Florczykowski B, Fahmy M. Current and future state of clinical pharmacist‐led precision medicine initiatives. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Monica Fahmy
- American College of Clinical Pharmacy Lenexa Kansas USA
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37
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Undurraga J, Bórquez-Infante I, Crossley NA, Prieto ML, Repetto GM. Pharmacogenetics in Psychiatry: Perceived Value and Opinions in a Chilean Sample of Practitioners. Front Pharmacol 2021; 12:657985. [PMID: 33935777 PMCID: PMC8082421 DOI: 10.3389/fphar.2021.657985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/08/2021] [Indexed: 12/11/2022] Open
Abstract
Use of pharmacogenetics (PGx) testing to guide clinical decisions is growing in developed countries. Published guidelines for gene–drug pair analysis are available for prescriptions in psychiatry, but information on their utilization, barriers, and health outcomes in Latin America is limited. As a result, this work aimed at exploring current use, opinions, and perceived obstacles on PGx testing among psychiatrists in Chile, via an online, anonymous survey. Among 123 respondents (5.9% of registered psychiatrists in the country), 16.3% reported ever requesting a PGx test. The vast majority (95%) of tests were ordered by clinicians practicing in the Metropolitan Region of Santiago. Having more than 20 years in practice was positively associated with prior use of PGx (p 0.02, OR 3.74 (1.19–11.80)), while working in the public health system was negatively associated (OR 0.30 (0.10–0.83)). Perceived barriers to local implementation included insufficient evidence of clinical utility, limited clinicians’ knowledge on PGx and on test availability, and health systems’ issues, such as costs and reimbursement. Despite the recognition of these barriers, 80% of respondents asserted that it is likely that they will incorporate PGx tests in their practice in the next five years. Given these results, we propose next steps to facilitate implementation such as further research in health outcomes and clinical utility of known and novel clinically actionable variants, growth in local sequencing capabilities, education of clinicians, incorporation of clinical decision support tools, and economic evaluations, all in local context.
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Affiliation(s)
- Juan Undurraga
- Department of Neurology and Psychiatry, Clínica Alemana Universidad Del Desarrollo, Santiago, Chile.,Early Intervention Program, Instituto Psiquiátrico Dr J. Horwitz Barak, Santiago, Chile
| | | | - Nicolás A Crossley
- Department of Psychiatry, Pontificia Universidad Católica de Chile, Santiago, Chile.,Biomedical Imaging Center, Pontificia Universidad Católica de Chile, Santiago, Chile.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Miguel L Prieto
- Department of Psychiatry, Faculty of Medicine, Universidad de Los Andes, Santiago, Chile.,Mental Health Service, Clínica Universidad de Los Andes, Santiago, Chile.,Center for Biomedical Research and Innovation, Universidad de Los Andes, Santiago, Chile.,Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Gabriela M Repetto
- Center for Genetics and Genomics, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clínica Alemana Universidad Del Desarrollo, Santiago, Chile.,Department of Pediatrics, Clínica Alemana, Santiago, Chile
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38
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Luczak T, Brown SJ, Armbruster D, Hundertmark M, Brown J, Stenehjem D. Strategies and settings of clinical pharmacogenetic implementation: a scoping review of pharmacogenetics programs. Pharmacogenomics 2021; 22:345-364. [PMID: 33829852 DOI: 10.2217/pgs-2020-0181] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pharmacogenetic (PGx) literature has shown beneficial outcomes in safety, efficacy and cost when evidence-based gene-drug decision making is incorporated into clinical practice. PGx programs with successfully implemented clinical services have been published in a variety of settings including academic health centers and community practice. The primary objective was to systematically scope the literature to characterize the current trends, extent, range and nature of clinical PGx programs. Forty articles representing 19 clinical PGx programs were included in analysis. Most programs are in urban, academic institutions. Education, governance and workflow were commonly described while billing/reimbursement and consent were not. This review provides an overview of current PGx models that can be used as a reference for institutions beginning the implementation process.
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Affiliation(s)
- Tiana Luczak
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA.,Essentia Health, Duluth, MN 55805, USA
| | - Sarah Jane Brown
- Health Sciences Libraries, University of Minnesota, MN 55455, USA
| | - Danielle Armbruster
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
| | - Megan Hundertmark
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
| | - Jacob Brown
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
| | - David Stenehjem
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
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39
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Stancil SL, Berrios C, Abdel-Rahman S. Adolescent perceptions of pharmacogenetic testing. Pharmacogenomics 2021; 22:335-343. [PMID: 33849282 PMCID: PMC8173518 DOI: 10.2217/pgs-2020-0177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Despite the expansion of pharmacogenetics (PGx), the views of pediatric patients remain unknown. This study explores adolescents' understanding and perceptions of PGx testing. Methods: Adolescents who had PGx testing were interviewed and their electronic health records were reviewed. Results: Adolescents accurately described reason for testing and most felt the results impacted their current and future care. None perceived risks to securing future employment or insurance. All felt PGx would benefit their peers. Conclusion: Adolescents understand the reasons for PGx and perceive testing to be useful, low risk and applicable to peers. Findings from this study advocate for the inclusion of adolescents in shared decision-making regarding testing and for active engagement in the discussion of results.
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Affiliation(s)
- Stephani L Stancil
- Division of Adolescent Medicine, Children’s Mercy Kansas City, MO 64108, USA
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, MO 64108, USA
| | - Courtney Berrios
- Genomic Medicine Center, Children’s Mercy Kansas City, MO 64108, USA
| | - Susan Abdel-Rahman
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, MO 64108, USA
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40
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Raccor BS, Thompson DK, Thomas C, Hill AK, Shields K, Alcala-Williams I, Cartrette T, Fasinu P, Al-Achi A. Assessment and clinical utility of pharmacogenomics by healthcare practitioners in North Carolina. Pharmacogenomics 2020; 22:13-25. [PMID: 33356552 DOI: 10.2217/pgs-2020-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Perceived knowledge, use and perceptions of pharmacogenomics (PGx) testing were assessed among healthcare practitioners in North Carolina. Materials & methods: A validated survey was distributed to various healthcare professionals and analyzed for differences among the groups. Results: The majority of the 744 survey respondents acknowledged the perceived benefits of PGx testing, but indicated either never or rarely using it. A substantial percentage of practitioners reported educational experiences but the majority had received no training. Among groups reporting using PGx testing, barriers to implementation were cost and insufficient training. Conclusion: The perceived cost of PGx testing and insufficiency or lack of training are major contributing factors to the infrequent use of PGx testing by healthcare providers in North Carolina.
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Affiliation(s)
- Brianne S Raccor
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA.,College of Arts & Sciences, Trinity Washington University, 125 Michigan Ave NE, Washington, DC 20017, USA
| | - Dorothea K Thompson
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
| | - Chantley Thomas
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
| | - Amber K Hill
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
| | - Kaitlin Shields
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
| | - Isabel Alcala-Williams
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
| | - Tristyn Cartrette
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA.,Southeastern Regional Medical Center, 300 W 27th St, Lumberton, NC 28358, USA
| | - Pius Fasinu
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
| | - Antoine Al-Achi
- College of Pharmacy & Health Sciences, Campbell University, Post Office Box 1090, Buies Creek, NC 27506, USA
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Malsagova KA, Butkova TV, Kopylov AT, Izotov AA, Potoldykova NV, Enikeev DV, Grigoryan V, Tarasov A, Stepanov AA, Kaysheva AL. Pharmacogenetic Testing: A Tool for Personalized Drug Therapy Optimization. Pharmaceutics 2020; 12:E1240. [PMID: 33352764 PMCID: PMC7765968 DOI: 10.3390/pharmaceutics12121240] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022] Open
Abstract
Pharmacogenomics is a study of how the genome background is associated with drug resistance and how therapy strategy can be modified for a certain person to achieve benefit. The pharmacogenomics (PGx) testing becomes of great opportunity for physicians to make the proper decision regarding each non-trivial patient that does not respond to therapy. Although pharmacogenomics has become of growing interest to the healthcare market during the past five to ten years the exact mechanisms linking the genetic polymorphisms and observable responses to drug therapy are not always clear. Therefore, the success of PGx testing depends on the physician's ability to understand the obtained results in a standardized way for each particular patient. The review aims to lead the reader through the general conception of PGx and related issues of PGx testing efficiency, personal data security, and health safety at a current clinical level.
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Affiliation(s)
- Kristina A. Malsagova
- Biobanking Group, Branch of Institute of Biomedical Chemistry “Scientific and Education Center”, 109028 Moscow, Russia; (T.V.B.); (A.T.K.); (A.A.I.); (A.A.S.); (A.L.K.)
| | - Tatyana V. Butkova
- Biobanking Group, Branch of Institute of Biomedical Chemistry “Scientific and Education Center”, 109028 Moscow, Russia; (T.V.B.); (A.T.K.); (A.A.I.); (A.A.S.); (A.L.K.)
| | - Arthur T. Kopylov
- Biobanking Group, Branch of Institute of Biomedical Chemistry “Scientific and Education Center”, 109028 Moscow, Russia; (T.V.B.); (A.T.K.); (A.A.I.); (A.A.S.); (A.L.K.)
| | - Alexander A. Izotov
- Biobanking Group, Branch of Institute of Biomedical Chemistry “Scientific and Education Center”, 109028 Moscow, Russia; (T.V.B.); (A.T.K.); (A.A.I.); (A.A.S.); (A.L.K.)
| | - Natalia V. Potoldykova
- Institute of Urology and Reproductive Health, Sechenov University, 119992 Moscow, Russia; (N.V.P.); (D.V.E.); (V.G.)
| | - Dmitry V. Enikeev
- Institute of Urology and Reproductive Health, Sechenov University, 119992 Moscow, Russia; (N.V.P.); (D.V.E.); (V.G.)
| | - Vagarshak Grigoryan
- Institute of Urology and Reproductive Health, Sechenov University, 119992 Moscow, Russia; (N.V.P.); (D.V.E.); (V.G.)
| | - Alexander Tarasov
- Institute of Linguistics and Intercultural Communication, Sechenov University, 119992 Moscow, Russia;
| | - Alexander A. Stepanov
- Biobanking Group, Branch of Institute of Biomedical Chemistry “Scientific and Education Center”, 109028 Moscow, Russia; (T.V.B.); (A.T.K.); (A.A.I.); (A.A.S.); (A.L.K.)
| | - Anna L. Kaysheva
- Biobanking Group, Branch of Institute of Biomedical Chemistry “Scientific and Education Center”, 109028 Moscow, Russia; (T.V.B.); (A.T.K.); (A.A.I.); (A.A.S.); (A.L.K.)
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Brown JT, Ramsey LB, Van Driest SL, Aka I, Colace SI. Characterizing Pharmacogenetic Testing Among Children's Hospitals. Clin Transl Sci 2020; 14:692-701. [PMID: 33325650 PMCID: PMC7993279 DOI: 10.1111/cts.12931] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/12/2020] [Indexed: 12/27/2022] Open
Abstract
Although pharmacogenetic testing is becoming increasingly common across medical subspecialties, a broad range of utilization and implementation exists across pediatric centers. Large pediatric institutions that routinely use pharmacogenetics in their patient care have published their practices and experiences; however, minimal data exist regarding the full spectrum of pharmacogenetic implementation among children’s hospitals. The primary objective of this nationwide survey was to characterize the availability, concerns, and barriers to pharmacogenetic testing in children’s hospitals in the Children’s Hospital Association. Initial responses identifying a contact person were received from 18 institutions. Of those 18 institutions, 14 responses (11 complete and 3 partial) to a more detailed survey regarding pharmacogenetic practices were received. The majority of respondents were from urban institutions (72%) and held a Doctor of Pharmacy degree (67%). Among all respondents, the three primary barriers to implementing pharmacogenetic testing identified were test reimbursement, test cost, and money. Conversely, the three least concerning barriers were potential for genetic discrimination, sharing results with family members, and availability of tests in certified laboratories. Low‐use sites rated several barriers significantly higher than the high‐use sites, including knowledge of pharmacogenetics (P = 0.03), pharmacogenetic interpretations (P = 0.04), and pharmacogenetic‐based changes to therapy (P = 0.03). In spite of decreasing costs of pharmacogenetic testing, financial barriers are one of the main barriers perceived by pediatric institutions attempting clinical implementation. Low‐use sites may also benefit from education/outreach in order to reduce perceived barriers to implementation.
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Affiliation(s)
- Jacob T Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota Duluth, Duluth, Minnesota, USA
| | - Laura B Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan I Colace
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
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43
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Vassy JL, Gaziano JM, Green RC, Ferguson RE, Advani S, Miller SJ, Chun S, Hage AK, Seo SJ, Majahalme N, MacMullen L, Zimolzak AJ, Brunette CA. Effect of Pharmacogenetic Testing for Statin Myopathy Risk vs Usual Care on Blood Cholesterol: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2027092. [PMID: 33270123 PMCID: PMC7716196 DOI: 10.1001/jamanetworkopen.2020.27092] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Nonadherence to statin guidelines is common. The solute carrier organic anion transporter family member 1B1 (SLCO1B1) genotype is associated with simvastatin myopathy risk and is proposed for clinical implementation. The unintended harms of using pharmacogenetic information to guide pharmacotherapy remain a concern for some stakeholders. OBJECTIVE To determine the impact of delivering SLCO1B1 pharmacogenetic results to physicians on the effectiveness of atherosclerotic cardiovascular disease (ASCVD) prevention (measured by low-density lipoprotein cholesterol [LDL-C] levels) and concordance with prescribing guidelines for statin safety and effectiveness. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed from December 2015 to July 2019 at 8 primary care practices in the Veterans Affairs Boston Healthcare System. Participants included statin-naive patients with elevated ASCVD risk. Data analysis was performed from October 2019 to September 2020. INTERVENTIONS SLCO1B1 genotyping and results reporting to primary care physicians at baseline (intervention group) vs after 1 year (control group). MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year change in LDL-C level. The secondary outcomes were 1-year concordance with American College of Cardiology-American Heart Association and Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for statin therapy and statin-associated muscle symptoms (SAMS). RESULTS Among 408 patients (mean [SD] age, 64.1 [7.8] years; 25 women [6.1%]), 193 were randomized to the intervention group and 215 were randomized to the control group. Overall, 120 participants (29%) had a SLCO1B1 genotype indicating increased simvastatin myopathy risk. Physicians offered statin therapy to 65 participants (33.7%) in the intervention group and 69 participants (32.1%) in the control group. Compared with patients whose physicians did not know their SLCO1B1 results at baseline, patients whose physicians received the results had noninferior reductions in LDL-C at 12 months (mean [SE] change in LDL-C, -1.1 [1.2] mg/dL in the intervention group and -2.2 [1.3] mg/dL in the control group; difference, -1.1 mg/dL; 90% CI, -4.1 to 1.8 mg/dL; P < .001 for noninferiority margin of 10 mg/dL). The proportion of patients with American College of Cardiology-American Heart Association guideline-concordant statin prescriptions in the intervention group was noninferior to that in the control group (12 patients [6.2%] vs 14 patients [6.5%]; difference, -0.003; 90% CI, -0.038 to 0.032; P < .001 for noninferiority margin of 15%). All patients in both groups were concordant with CPIC guidelines for safe statin prescribing. Physicians documented 2 and 3 cases of SAMS in the intervention and control groups, respectively, none of which was associated with a CPIC guideline-discordant prescription. Among patients with a decreased or poor SLCO1B1 transporter function genotype, simvastatin was prescribed to 1 patient in the control group but none in the intervention group. CONCLUSIONS AND RELEVANCE Clinical testing and reporting of SLCO1B1 results for statin myopathy risk did not result in poorer ASCVD prevention in a routine primary care setting and may have been associated with physicians avoiding simvastatin prescriptions for patients at genetic risk for SAMS. Such an absence of harm should reassure stakeholders contemplating the clinical use of available pharmacogenetic results. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02871934.
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Affiliation(s)
- Jason L. Vassy
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Ariadne Labs, Boston, Massachusetts
| | - J. Michael Gaziano
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Robert C. Green
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Ariadne Labs, Boston, Massachusetts
| | - Ryan E. Ferguson
- VA Boston Healthcare System, Boston, Massachusetts
- Department of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | | | | | - Sojeong Chun
- Massachusetts College of Pharmacy and Health Sciences, Boston
| | - Anthony K. Hage
- Massachusetts College of Pharmacy and Health Sciences, Boston
| | - Soo-Ji Seo
- Massachusetts College of Pharmacy and Health Sciences, Boston
| | | | | | - Andrew J. Zimolzak
- VA Boston Healthcare System, Boston, Massachusetts
- Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
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44
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Dafniet B, Cerisier N, Audouze K, Taboureau O. Drug-target-ADR Network and Possible Implications of Structural Variants in Adverse Events. Mol Inform 2020; 39:e2000116. [PMID: 32725965 PMCID: PMC8047896 DOI: 10.1002/minf.202000116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
Abstract
Adverse drug reactions (ADRs) are of major concern in drug safety. However, due to the biological complexity of human systems, understanding the underlying mechanisms involved in development of ADRs remains a challenging task. Here, we applied network sciences to analyze a tripartite network between 1000 drugs, 1407 targets, and 6164 ADRs. It allowed us to suggest drug targets susceptible to be associated to ADRs and organs, based on the system organ class (SOC). Furthermore, a score was developed to determine the contribution of a set of proteins to ADRs. Finally, we identified proteins that might increase the susceptibility of genes to ADRs, on the basis of knowledge about genomic structural variation in genes encoding proteins targeted by drugs. Such analysis should pave the way to individualize drug therapy and precision medicine.
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Affiliation(s)
- Bryan Dafniet
- Université de ParisINSERM U1133, CNRS UMR 825175006ParisFrance
| | | | - Karine Audouze
- Université de ParisT3S, INSERM UMR S-112475006ParisFrance
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45
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Shugg T, Pasternak AL, London B, Luzum JA. Prevalence and types of inconsistencies in clinical pharmacogenetic recommendations among major U.S. sources. NPJ Genom Med 2020; 5:48. [PMID: 33145028 PMCID: PMC7603298 DOI: 10.1038/s41525-020-00156-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022] Open
Abstract
Clinical implementation of pharmacogenomics (PGx) is slow. Previous studies have identified some inconsistencies among clinical PGx recommendations, but the prevalence and types of inconsistencies have not been comprehensively analyzed among major PGx guidance sources in the U.S. PGx recommendations from the Clinical Pharmacogenetics Implementation Consortium, U.S. Food and Drug Administration drug labels, and major U.S. professional medical organizations were analyzed through May 24, 2019. Inconsistencies were analyzed within the following elements: recommendation category; whether routine screening was recommended; and the specific biomarkers, variants, and patient groups involved. We identified 606 total clinical PGx recommendations, which contained 267 unique drugs. Composite inconsistencies occurred in 48.1% of clinical PGx recommendations overall, and in 93.3% of recommendations from three sources. Inconsistencies occurred in the recommendation category (29.8%), the patient group (35.4%), and routine screening (15.2%). In conclusion, almost one-half of clinical PGx recommendations from prominent U.S. guidance sources contain inconsistencies, which can potentially slow clinical implementation.
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Affiliation(s)
- Tyler Shugg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI USA.,Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN USA
| | - Amy L Pasternak
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI USA
| | - Bianca London
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI USA.,Senior Health Services at Blue Cross Blue Shield of Michigan Emerging Markets, Southfield, MI USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI USA
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46
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Lee CR, Thomas CD, Beitelshees AL, Tuteja S, Empey PE, Lee JC, Limdi NA, Duarte JD, Skaar TC, Chen Y, Cook KJ, Coons JC, Dillon C, Franchi F, Giri J, Gong Y, Kreutz RP, McDonough CW, Stevenson JM, Weck KE, Angiolillo DJ, Johnson JA, Stouffer GA, Cavallari LH. Impact of the CYP2C19*17 Allele on Outcomes in Patients Receiving Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2020; 109:705-715. [PMID: 32897581 DOI: 10.1002/cpt.2039] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/18/2020] [Indexed: 01/03/2023]
Abstract
Genotyping for CYP2C19 no function alleles to guide antiplatelet therapy after percutaneous coronary intervention (PCI) improves clinical outcomes. Although results for the increased function CYP2C19*17 allele are also reported, its clinical relevance in this setting remains unclear. A collaboration across nine sites examined antiplatelet therapy prescribing and clinical outcomes in 3,342 patients after implementation of CYP2C19-guided antiplatelet therapy. Risk of major atherothrombotic and bleeding events over 12 months after PCI were compared across cytochrome P450 2C19 isozyme (CYP2C19) metabolizer phenotype and antiplatelet therapy groups by proportional hazards regression. Clopidogrel was prescribed to a similar proportion of CYP2C19 normal (84.5%), rapid (82.9%), and ultrarapid metabolizers (80.6%) (P = 0.360). Clopidogrel-treated normal metabolizers (20.4 events/100 patient-years; adjusted hazard ratio (HR) 1.00, 95% confidence interval (CI), 0.75-1.33, P = 0.993) and clopidogrel-treated rapid or ultrarapid metabolizers (19.1 events/100 patient-years; adjusted HR 0.95, 95% CI, 0.69-1.30, P = 0.734) exhibited no difference in major atherothrombotic events compared with patients treated with prasugrel or ticagrelor (17.6 events/100 patient-years). In contrast, clopidogrel-treated intermediate and poor metabolizers exhibited significantly higher atherothrombotic event risk compared with prasugrel/ticagrelor-treated patients (adjusted HR 1.56, 95% CI, 1.12-2.16, P = 0.008). When comparing clopidogrel-treated rapid or ultrarapid metabolizers to normal metabolizers, no difference in atherothrombotic (adjusted HR 0.97, 95% CI, 0.73-1.29, P = 0.808) or bleeding events (adjusted HR 1.34, 95% CI, 0.83-2.17, P = 0.224) were observed. In a real-world setting of genotype-guided antiplatelet therapy, the CYP2C19*17 allele did not significantly impact post-PCI prescribing decisions or clinical outcomes. These results suggest the CYP2C19 *1/*17 and *17/*17 genotypes have limited clinical utility to guide antiplatelet therapy after PCI.
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Affiliation(s)
- Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip E Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nita A Limdi
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yiqing Chen
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James C Coons
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chrisly Dillon
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James M Stevenson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen E Weck
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
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47
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Takahashi T, Luzum JA, Nicol MR, Jacobson PA. Pharmacogenomics of COVID-19 therapies. NPJ Genom Med 2020; 5:35. [PMID: 32864162 PMCID: PMC7435176 DOI: 10.1038/s41525-020-00143-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023] Open
Abstract
A new global pandemic of coronavirus disease 2019 (COVID-19) has resulted in high mortality and morbidity. Currently numerous drugs are under expedited investigations without well-established safety or efficacy data. Pharmacogenomics may allow individualization of these drugs thereby improving efficacy and safety. In this review, we summarized the pharmacogenomic literature available for COVID-19 drug therapies including hydroxychloroquine, chloroquine, azithromycin, remdesivir, favipiravir, ribavirin, lopinavir/ritonavir, darunavir/cobicistat, interferon beta-1b, tocilizumab, ruxolitinib, baricitinib, and corticosteroids. We searched PubMed, reviewed the Pharmacogenomics Knowledgebase (PharmGKB®) website, Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines, the U.S. Food and Drug Administration (FDA) pharmacogenomics information in the product labeling, and the FDA pharmacogenomics association table. We found several drug-gene variant pairs that may alter the pharmacokinetics of hydroxychloroquine/chloroquine (CYP2C8, CYP2D6, SLCO1A2, and SLCO1B1); azithromycin (ABCB1); ribavirin (SLC29A1, SLC28A2, and SLC28A3); and lopinavir/ritonavir (SLCO1B1, ABCC2, CYP3A). We also identified other variants, that are associated with adverse effects, most notable in hydroxychloroquine/chloroquine (G6PD; hemolysis), ribavirin (ITPA; hemolysis), and interferon β -1b (IRF6; liver toxicity). We also describe the complexity of the risk for QT prolongation in this setting because of additive effects of combining more than one QT-prolonging drug (i.e., hydroxychloroquine/chloroquine and azithromycin), increased concentrations of the drugs due to genetic variants, along with the risk of also combining therapy with potent inhibitors. In conclusion, although direct evidence in COVID-19 patients is lacking, we identified potential actionable genetic markers in COVID-19 therapies. Clinical studies in COVID-19 patients are deemed warranted to assess potential roles of these markers.
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Affiliation(s)
- Takuto Takahashi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy University of Minnesota, Minneapolis, MN USA
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI USA
| | - Melanie R. Nicol
- Department of Experimental and Clinical Pharmacology, College of Pharmacy University of Minnesota, Minneapolis, MN USA
| | - Pamala A. Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy University of Minnesota, Minneapolis, MN USA
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48
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Scott SA, Scott ER, Seki Y, Chen AJ, Wallsten R, Owusu Obeng A, Botton MR, Cody N, Shi H, Zhao G, Brake P, Nicoletti P, Yang Y, Delio M, Shi L, Kornreich R, Schadt EE, Edelmann L. Development and Analytical Validation of a 29 Gene Clinical Pharmacogenetic Genotyping Panel: Multi-Ethnic Allele and Copy Number Variant Detection. Clin Transl Sci 2020; 14:204-213. [PMID: 32931151 PMCID: PMC7877843 DOI: 10.1111/cts.12844] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022] Open
Abstract
To develop a novel pharmacogenetic genotyping panel, a multidisciplinary team evaluated available evidence and selected 29 genes implicated in interindividual drug response variability, including 130 sequence variants and additional copy number variants (CNVs). Of the 29 genes, 11 had guidelines published by the Clinical Pharmacogenetics Implementation Consortium. Targeted genotyping and CNV interrogation were accomplished by multiplex single‐base extension using the MassARRAY platform (Agena Biosciences) and multiplex ligation‐dependent probe amplification (MRC Holland), respectively. Analytical validation of the panel was accomplished by a strategic combination of > 500 independent tests performed on 170 unique reference material DNA samples, which included sequence variant and CNV accuracy, reproducibility, and specimen (blood, saliva, and buccal swab) controls. Among the accuracy controls were 32 samples from the 1000 Genomes Project that were selected based on their enrichment of sequence variants included in the pharmacogenetic panel (VarCover.org). Coupled with publicly available samples from the Genetic Testing Reference Materials Coordination Program (GeT‐RM), accuracy validation material was available for the majority (77%) of interrogated sequence variants (100% with average allele frequencies > 0.1%), as well as additional structural alleles with unique copy number signatures (e.g., CYP2D6*5, *13, *36, *68; CYP2B6*29; and CYP2C19*36). Accuracy and reproducibility for both genotyping and copy number were > 99.9%, indicating that the optimized panel platforms were precise and robust. Importantly, multi‐ethnic allele frequencies of the interrogated variants indicate that the vast majority of the general population carries at least one of these clinically relevant pharmacogenetic variants, supporting the implementation of this panel for pharmacogenetic research and/or clinical implementation programs.
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Affiliation(s)
- Stuart A Scott
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erick R Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | - Aniwaa Owusu Obeng
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mariana R Botton
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Neal Cody
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | - Paola Nicoletti
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yao Yang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Lisong Shi
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ruth Kornreich
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric E Schadt
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lisa Edelmann
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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49
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Hoffman JM, Flynn AJ, Juskewitch JE, Freimuth RR. Biomedical Data Science and Informatics Challenges to Implementing Pharmacogenomics with Electronic Health Records. Annu Rev Biomed Data Sci 2020. [DOI: 10.1146/annurev-biodatasci-020320-093614] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pharmacogenomic information must be incorporated into electronic health records (EHRs) with clinical decision support in order to fully realize its potential to improve drug therapy. Supported by various clinical knowledge resources, pharmacogenomic workflows have been implemented in several healthcare systems. Little standardization exists across these efforts, however, which limits scalability both within and across clinical sites. Limitations in information standards, knowledge management, and the capabilities of modern EHRs remain challenges for the widespread use of pharmacogenomics in the clinic, but ongoing efforts are addressing these challenges. Although much work remains to use pharmacogenomic information more effectively within clinical systems, the experiences of pioneering sites and lessons learned from those programs may be instructive for other clinical areas beyond genomics. We present a vision of what can be achieved as informatics and data science converge to enable further adoption of pharmacogenomics in the clinic.
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Affiliation(s)
- James M. Hoffman
- Department of Pharmaceutical Sciences and the Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Allen J. Flynn
- Department of Learning Health Sciences, Medical School, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Justin E. Juskewitch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Robert R. Freimuth
- Division of Digital Health Sciences, Department of Health Sciences Research, Center for Individualized Medicine, and Information and Knowledge Management, Mayo Clinic, Rochester, Minnesota 55905, USA
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50
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Marrero RJ, Cicali EJ, Arwood MJ, Eddy E, DeRemer D, Ramnaraign BH, Daily KC, Jones D, Cook KJ, Cavallari LH, Wiisanen Weitzel K, Langaee T, Newsom KJ, Starostik P, Clare-Salzer MJ, Johnson JA, George TJ, Cooper-DeHoff RM. How to Transition from Single-Gene Pharmacogenetic Testing to Preemptive Panel-Based Testing: A Tutorial. Clin Pharmacol Ther 2020; 108:557-565. [PMID: 32460360 DOI: 10.1002/cpt.1912] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/08/2020] [Indexed: 12/14/2022]
Abstract
There have been significant advancements in precision medicine and approaches to medication selection based on pharmacogenetic results. With the availability of direct-to-consumer genetic testing and growing awareness of genetic interindividual variability, patient demand for more precise, individually tailored drug regimens is increasing. The University of Florida (UF) Health Precision Medicine Program (PMP) was established in 2011 to improve integration of genomic data into clinical practice. In the ensuing years, the UF Health PMP has successfully implemented several single-gene tests to optimize the precision of medication prescribing across a variety of clinical settings. Most recently, the UF Health PMP launched a custom-designed pharmacogenetic panel, including pharmacogenes relevant to supportive care medications commonly prescribed to patients undergoing chemotherapy treatment, referred to as "GatorPGx." This tutorial provides guidance and information to institutions on how to transition from the implementation of single-gene pharmacogenetic testing to a preemptive panel-based testing approach. Here, we demonstrate application of the preemptive panel in the setting of an adult solid tumor oncology clinic. Importantly, the information included herein can be applied to other clinical practice settings.
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Affiliation(s)
- Richard J Marrero
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Emily J Cicali
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Meghan J Arwood
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Elizabeth Eddy
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - David DeRemer
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | - Karen C Daily
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Dennie Jones
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Kristin Wiisanen Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Kimberly J Newsom
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Michael J Clare-Salzer
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Thomas J George
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, Florida, USA
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