Pharmacogenetics and pharmacogenomics: recent developments, their clinical relevance and some ethical, social, and legal implications

Pharmacogenomics in Children

Historically genetics has not been considered when prescribing drugs for children. However, it is clear that genetics are not only an important determinant of disease in children but also of drug response for many important drugs that are core agents used in the therapy of common problems in children. Advances in therapy and in the ethical construct of children's research have made pharmacogenomic assessment for children much easier to pursue. It is likely that pharmacogenomics will become part of the therapeutic decision-making process for children, notably in areas such as childhood cancer where weighing benefits and risks of therapy is crucial.

Biopiracy versus One-World Medicine-From colonial relicts to global collaborative concepts

BACKGROUND

Practices of biopiracy to use genetic resources and indigenous knowledge by Western companies without benefit-sharing of those, who generated the traditional knowledge, can be understood as form of neocolonialism.

HYPOTHESIS

The One-World Medicine concept attempts to merge the best of traditional medicine from developing countries and conventional Western medicine for the sake of patients around the globe.

STUDY DESIGN

Based on literature searches in several databases, a concept paper has been written. Legislative initiatives of the United Nations culminated in the Nagoya protocol aim to protect traditional knowledge and regulate benefit-sharing with indigenous communities. The European community adopted the Nagoya protocol, and the corresponding regulations will be implemented into national legislation among the member states. Despite pleasing progress, infrastructural problems of the health care systems in developing countries still remain. Current approaches to secure primary health care offer only fragmentary solutions at best. Conventional medicine from industrialized countries cannot be afforded by the impoverished population in the Third World. Confronted with exploding costs, even health systems in Western countries are endangered to burst. Complementary and alternative medicine (CAM) is popular among the general public in industrialized countries, although the efficacy is not sufficiently proven according to the standards of evidence-based medicine. CAM is often available without prescription as over-the-counter products with non-calculated risks concerning erroneous self-medication and safety/toxicity issues. The concept of integrative medicine attempts to combine holistic CAM approaches with evidence-based principles of conventional medicine.

CONCLUSION

To realize the concept of One-World Medicine, a number of standards have to be set to assure safety, efficacy and applicability of traditional medicine, e.g. sustainable production and quality control of herbal products, performance of placebo-controlled, double-blind, randomized clinical trials, phytovigilance, as well as education of health professionals and patients.

Public perceptions of pharmacogenetics

BACKGROUND AND OBJECTIVES

Pharmacogenetics (PGx) promises to optimize patient response to therapy. However, the public's acceptance of PGx is not well known, notably when this applies to children. Our objective was to explore perceptions of PGx testing among individuals, who differ from each other by either parental status or educational exposure to PGx, and to explore parents' views between PGx testing for oneself and PGx testing for their children.

METHODS

An exploratory survey was conducted among parents and other adults. Surveys P and C were completed by parents, survey NP by middle-aged nonparents, and survey MS by medical students.

RESULTS

Proper explanation before PGx testing appeared to be the most important issue to the respondents (eg, P = 1.55 × 10(-38) for survey NP). Respondents who were more knowledgeable about PGx were also more comfortable with PGx testing (eg, P = 2.53 × 10(-7) in case of mild disease). When PGx testing was for one's child, parents valued their own understanding more than their child's assent (P = 1.57 × 10(-17)).

CONCLUSIONS

The acceptability of PGx testing, either for oneself or for one's child, seemed to depend on baseline PGx knowledge, but not on parenthood.

Pharmacogenomics and adverse drug reactions in children

Adverse drug reactions are a common and important complication of drug therapy in children. Over the past decade it has become increasingly apparent that genetically controlled variations in drug disposition and response are important determinants of adverse events for many important adverse events associated with drug therapy in children. While this research has been difficult to conduct over the past decade technical and ethical evolution has greatly facilitated the ability of investigators to conduct pharmacogenomic studies in children. Some of this research has already resulted in changes in public policy and clinical practice, for example in the case of codeine use by mothers and children. It is likely that the use of pharmacogenomics to enhance drug safety will first be realized among selected groups of children with high rates of drug use such as children with cancer, but it also likely that this research will be extended to other groups of children who have high rates of drug utilization and as well as providing insights into the mechanisms and pathophysiology of adverse drug reactions in children.

Pharmacogenomics in children

Historically genetics has not been considered when prescribing drugs for children. However, it is clear that genetics are not only an important determinant of disease in children but also of drug response for many important drugs that are core agents used in the therapy of common problems in children. Advances in therapy and in the ethical construct of children's research have made pharmacogenomic assessment for children much easier to pursue. It is likely that pharmacogenomics will become part of the therapeutic decision making process for children, notably in areas such as childhood cancer where the benefits and risks of therapy are considerable.

Captious certainties: makings, meanings and misreadings of consumer-oriented genetic testing

Members of the scientific and medical communities concerned with genetic testing might wonder, why cultural and ethical analyses of genetic testing are increasing again, especially since legal frameworks have, by now, come to provide more solid grounds for the routine application of genetic testing on both levels of application, diagnostics, and prediction. This contribution aims to shed light on the changing concept of genetic testing as it is raised by novel cultural practices and perceptions mainly triggered by direct-to-consumer predictive testing, including the phenomenon of a new genetic exceptionalism "from below". We are seeking to determine what is at stake in this practice and what consequences arise from it for the medical and scientific community. What exactly happens as we move from diagnostic to prognostic medicine? Above all, this article pivots on the notion of captious certainties, a concept, which we will elaborate on as our argument progresses.

Therapeutic Drug Monitoring and Pharmacogenetic Tests as Tools in Pharmacovigilance

Therapeutic drug monitoring (TDM) and pharmacogenetic tests play a major role in minimising adverse drug reactions and enhancing optimal therapeutic response. The response to medication varies greatly between individuals, according to genetic constitution, age, sex, co-morbidities, environmental factors including diet and lifestyle (e.g. smoking and alcohol intake), and drug-related factors such as pharmacokinetic or pharmacodynamic drug-drug interactions. Most adverse drug reactions are type A reactions, i.e. plasma-level dependent, and represent one of the major causes of hospitalisation, in some cases leading to death. However, they may be avoidable to some extent if pharmacokinetic and pharmacogenetic factors are taken into consideration. This article provides a review of the literature and describes how to apply and interpret TDM and certain pharmacogenetic tests and is illustrated by case reports. An algorithm on the use of TDM and pharmacogenetic tests to help characterise adverse drug reactions is also presented. Although, in the scientific community, differences in drug response are increasingly recognised, there is an urgent need to translate this knowledge into clinical recommendations. Databases on drug-drug interactions and the impact of pharmacogenetic polymorphisms and adverse drug reaction information systems will be helpful to guide clinicians in individualised treatment choices.

Genomic medicine: bringing biomarkers to clinical medicine

An important by-product of sequencing the human genome has been the development of a novel 'toolbox' for biomarker discovery and development. Genomic medicine is an emerging discipline in the genome sciences that integrates these tools to interrogate genomic variation in well-defined populations in order to develop predictors of disease susceptibility, progression and drug response. Several important classes of biomarkers result from these analyses which, when translated to clinical medicine and drug development, will have an important impact on human health and disease. This review highlights both the opportunities and challenges in bringing biomarkers into clinical medicine.

Workshop Abstracts

The first and crucial step in sensory processing, the transduction of stimuli, such as odor, light and sound, into a cellular response, are all regulated by genetic pathways. The past years have provided a significant increase in our understanding of some of these pathways, due in large part to the genes found to be associated with inherited hearing loss (HL).

Ethics and research assessing the relative roles of genes and the environment

Research on the interaction of genes and the environment is revealing that many human diseases have both genetic and environmental components. Even traditional "environmental" diseases, such as infections, appear to interact with genetic components in the human host. Environmental genetics research will inevitably increase understanding of individual susceptibilities to toxic exposures in the environment and harmful side effects of medications; therefore, it has great promise for improving the prevention and treatment of human diseases. However, realizing the benefits of this research requires careful attention to ethical issues that are particularly relevant in this context. This article reviews some of the most pressing issues related to research design and methods, as well as from the application of research results (e.g., workplace genetic screening and legal toxic torts, personal medical responsibility, and the relationship between genetics and public health measures).

personalized medicine and pharmacogenomics: ethical and social challenges

Recent developments in human genetic variation research have fueled predictions of an imminent era of personalized medicine. Defined as a shift toward greater integrated and heuristic innovation in healthcare, personalized medicine seeks to create differentiated strategies for the prevention of disease defined at the molecular level [1] . Recent developments in gene sequencing technologies have focused efforts toward improving efficacy and efficiency in the drug development process. Emerging from the discipline of pharmacogenetics, pharmacogenomics - the study of gene-to-gene interactions through the use of high-throughput technologies - has gained attention as the field most able to deliver on the promises of genomic medicine [2] . The distinction between pharmacogenetics and pharmacogenomics is not clear; while some have argued that differences of scale and focus distinguish the fields, this article uses the term, 'pharmacogenomics', to mean the broad scope of research on inherited variation in drug response. Through differential diagnosis, drug response is being linked to molecular subgroups that may allow for the development of 'tailored' medications [3] . However, several challenges confront these potential benefits. Critical to the success of pharmacogenomics and personalized drug therapies are the creation of large databases containing human genotypic and phenotypic information, the adoption of pharmacogenomic testing as a standard of medical care, and greater regulatory guidance on balancing commercial and public health priorities. In anticipation of these healthcare trajectories, serious engagement with the ethical and social implications of pharmacogenomics is needed. This article reviews several of these issues and highlights concerns that must be addressed in anticipation of personalized drug development.