1
|
Tang Girdwood S, Hall M, Antoon JW, Kyler KE, Williams DJ, Shah SS, Orth LE, Goldman J, Feinstein JA, Ramsey LB. Opportunities for Pharmacogenetic Testing to Guide Dosing of Medications in Youths With Medicaid. JAMA Netw Open 2024; 7:e2355707. [PMID: 38349656 PMCID: PMC10865156 DOI: 10.1001/jamanetworkopen.2023.55707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/19/2023] [Indexed: 02/15/2024] Open
Abstract
Importance There are an increasing number of medications with a high level of evidence for pharmacogenetic-guided dosing (PGx drugs). Knowledge of the prevalence of dispensings of PGx drugs and their associated genes may allow hospitals and clinical laboratories to determine which pharmacogenetic tests to implement. Objectives To investigate the prevalence of outpatient dispensings of PGx drugs among Medicaid-insured youths, determine genes most frequently associated with PGx drug dispenses, and describe characteristics of youths who were dispensed at least 1 PGx drug. Design, Setting, and Participants This serial cross-sectional study includes data from 2011 to 2019 among youths aged 0 to 17 years in the Marketscan Medicaid database. Data were analyzed from August to December 2022. Main Outcomes and Measures PGx drugs were defined as any medication with level A evidence as determined by the Clinical Pharmacogenetics Implementation Consortium (CPIC). The number of unique youths dispensed each PGx drug in each year was determined. PGx drugs were grouped by their associated genes for which there was CPIC level A evidence to guide dosing, and a dispensing rate (No. of PGx drugs/100 000 youths) was determined for each group for the year 2019. Demographics were compared between youths dispensed at least 1 PGx drug and those not dispensed any PGx drugs. Results The number of Medicaid-insured youths queried ranged by year from 2 078 683 youths in 2011 to 4 641 494 youths in 2017, including 4 126 349 youths (median [IQR] age, 9 [5-13] years; 2 129 926 males [51.6%]) in 2019. The proportion of Medicaid-insured youths dispensed PGx drugs increased from 289 709 youths (13.9%; 95% CI, 13.8%-14.0%) in 2011 to 740 072 youths (17.9%; 95% CI, 17.9%-18.0%) in 2019. Genes associated with the most frequently dispensed medications were CYP2C9, CYP2D6, and CYP2C19 (9197.0 drugs [95% CI, 9167.7-9226.3 drugs], 8731.5 drugs [95% CI, 8702.5-8759.5 drugs], and 3426.8 drugs [95% CI, 3408.1-3443.9 drugs] per 100 000 youths, respectively). There was a higher percentage of youths with at least 1 chronic medical condition among youths dispensed at least 1 PGx drug (510 445 youths [69.0%; 95% CI, 68.8%-69.1%]) than among 3 386 277 youths dispensed no PGx drug (1 381 544 youths [40.8%; 95% CI, 40.7%-40.9%) (P < .001) in 2019. Conclusions and Relevance In this study, there was an increasing prevalence of dispensings for PGx drugs. This finding suggests that pharmacogenetic testing of specific drug-gene pairs should be considered for frequently prescribed PGx drugs and their implicated genes.
Collapse
Affiliation(s)
- Sonya Tang Girdwood
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - James W. Antoon
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathryn E. Kyler
- Division of Hospital Medicine, Children’s Mercy Kansas City, Kansas City, Missouri
- Division of Clinical Pharmacology, Children’s Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City
| | - Derek J. Williams
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samir S. Shah
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lucas E. Orth
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora
| | - Jennifer Goldman
- Division of Clinical Pharmacology, Children’s Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City
- Division of Infectious Diseases, Children’s Mercy Kansas City, Kansas City, Missouri
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children’s Hospital Colorado, University of Colorado, Aurora
| | - Laura B. Ramsey
- Division of Clinical Pharmacology, Children’s Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City
| |
Collapse
|
2
|
Friedman JM, Bombard Y, Carleton B, Issa AM, Knoppers B, Plon SE, Rahimzadeh V, Relling MV, Williams MS, van Karnebeek C, Vears D, Cornel MC. Should secondary pharmacogenomic variants be actively screened and reported when diagnostic genome-wide sequencing is performed in a child? Genet Med 2024; 26:101033. [PMID: 38007624 DOI: 10.1016/j.gim.2023.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023] Open
Abstract
This white paper was prepared by the Global Alliance for Genomics and Health Regulatory and Ethics Work Stream's Pediatric Task Team to review and provide perspective with respect to ethical, legal, and social issues regarding the return of secondary pharmacogenomic variants in children who have a serious disease or developmental disorder and are undergoing exome or genome sequencing to identify a genetic cause of their condition. We discuss actively searching for and reporting pharmacogenetic/genomic variants in pediatric patients, different methods of returning secondary pharmacogenomic findings to the patient/parents and/or treating clinicians, maintaining these data in the patient's health record over time, decision supports to assist using pharmacogenetic results in future treatment decisions, and sharing information in public databases to improve the clinical interpretation of pharmacogenetic variants identified in other children. We conclude by presenting a series of points to consider for clinicians and policymakers regarding whether, and under what circumstances, routine screening and return of pharmacogenomic variants unrelated to the indications for testing is appropriate in children who are undergoing genome-wide sequencing to assist in the diagnosis of a suspected genetic disease.
Collapse
Affiliation(s)
- Jan M Friedman
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Yvonne Bombard
- Genomics Health Services Research Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Carleton
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Amalia M Issa
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, MA; Health Policy, University of the Sciences, Philadelphia, PA; Pharmaceutical Sciences, University of the Sciences, Philadelphia, PA; Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Bartha Knoppers
- Centre of Genomics and Policy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Sharon E Plon
- Department of Pediatrics, Texas Children's Cancer and Hematology Center, Baylor College of Medicine, Houston, TX; Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Vasiliki Rahimzadeh
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Clara van Karnebeek
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, The Netherlands; Departments of Pediatrics and Human Genetics, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; United for Metabolic Diseases, The Netherlands; Radboud Center for Mitochondrial and Metabolic Medicine, Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Danya Vears
- University of Melbourne, Carlton, Melbourne, Australia; Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Martina C Cornel
- Department of Human Genetics and Amsterdam Public Health Research Institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Moore C, Lazaraki S, Stenta T, Alexander M, Nguyen RP, Elliott DA, Conyers R. A systematic review of knowledge, attitude and practice of pharmacogenomics in pediatric oncology patients. Pharmacol Res Perspect 2023; 11:e01150. [PMID: 38013228 PMCID: PMC10682497 DOI: 10.1002/prp2.1150] [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: 09/04/2023] [Accepted: 10/10/2023] [Indexed: 11/29/2023] Open
Abstract
Pharmacogenomics remains underutilized in clinical practice, despite the existence of internationally recognized, evidence-based guidelines. This systematic review aims to understand enablers and barriers to pharmacogenomics implementation in pediatric oncology by assessing the knowledge, attitudes, and practice of healthcare professionals and consumers. Medline, Embase, Emcare, and PsycINFO database searches identified 146 relevant studies of which only three met the inclusion criteria. These studies reveal that consumers were concerned with pharmacogenomic test costs, insurance discrimination, data sharing, and privacy. Healthcare professionals possessed mostly positive attitudes toward pharmacogenomic testing yet identified lack of experience and training as barriers to implementation. Education emerged as the key enabler, reported in all three studies and both healthcare professionals and consumer groups. However, despite the need for education, no studies utilizing a pediatric oncology consumer or healthcare professional group have reported on the implementation or analysis of a pharmacogenomic education program in pediatric oncology. Increased access to guidelines, expert collaborations and additional guidance interpreting results were further enablers established by healthcare professionals. The themes identified mirror those reported in broader pediatric genetic testing literature. As only a small number of studies met inclusion criteria for this review, further research is warranted to elicit implementation determinants and advance pediatric pharmacogenomics.
Collapse
Affiliation(s)
- Claire Moore
- Pharmacogenomics TeamMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of PaediatricsThe University of MelbourneParkvilleVictoriaAustralia
| | - Smaro Lazaraki
- Health Sciences LibraryRoyal Melbourne Hospital, Melbourne HealthParkvilleVictoriaAustralia
| | - Tayla Stenta
- Pharmacogenomics TeamMurdoch Children's Research InstituteParkvilleVictoriaAustralia
| | - Marliese Alexander
- Sir Peter MacCallum Department of OncologyThe University of MelbourneParkvilleVictoriaAustralia
- Pharmacy DepartmentPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | | | - David A. Elliott
- Pharmacogenomics TeamMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of PaediatricsThe University of MelbourneParkvilleVictoriaAustralia
- Pharmacy DepartmentPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Rachel Conyers
- Pharmacogenomics TeamMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of PaediatricsThe University of MelbourneParkvilleVictoriaAustralia
- The Novo Nordisk Foundation Centre for Stem Cell Medicine, ReNEW, Melbourne NodeParkvilleVictoriaAustralia
- Children's Cancer Centre, The Royal Children's HospitalParkvilleVictoriaAustralia
| |
Collapse
|
4
|
Ramsey LB, Prows CA, Tang Girdwood S, Van Driest S. Current Practices in Pharmacogenomics. Pediatr Clin North Am 2023; 70:995-1011. [PMID: 37704356 PMCID: PMC10865383 DOI: 10.1016/j.pcl.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Pharmacogenomics, where genomic information is used to tailor medication management, is a strategy to maximize drug efficacy and minimize toxicity. Although pediatric evidence is less robust than for adults, medications influenced by pharmacogenomics are prescribed to children and adolescents. Evidence-based guidelines and drug label annotations are available from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Pharmacogenomics Knowledgebase (PharmGKB). Some pediatric health care facilities use pharmacogenomics to provide dosing recommendations to pediatricians. Herein, we use a case-based approach to illustrate the use of pharmacogenomic data in pediatric clinical care and provide resources for finding and using pharmacogenomic guidelines.
Collapse
Affiliation(s)
- Laura B Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA; Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA.
| | - Cynthia A Prows
- Division of Human Genetics, Department of Pediatrics and Center for Professional Excellence, Patient Services, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA
| | - Sonya Tang Girdwood
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA
| | - Sara Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, 8232 DOT, Nashville, TN 37205, USA
| |
Collapse
|
5
|
Shaaban S, Ji Y. Pharmacogenomics and health disparities, are we helping? Front Genet 2023; 14:1099541. [PMID: 36755573 PMCID: PMC9900000 DOI: 10.3389/fgene.2023.1099541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Pharmacogenomics has been at the forefront of precision medicine during the last few decades. Precision medicine carries the potential of improving health outcomes at both the individual as well as population levels. To harness the benefits of its initiatives, careful dissection of existing health disparities as they relate to precision medicine is of paramount importance. Attempting to address the existing disparities at the early stages of design and implementation of these efforts is the only guarantee of a successful just outcome. In this review, we glance at a few determinants of existing health disparities as they intersect with pharmacogenomics research and implementation. In our opinion, highlighting these disparities is imperative for the purpose of researching meaningful solutions. Failing to identify, and hence address, these disparities in the context of the current and future precision medicine initiatives would leave an already strained health system, even more inundated with inequality.
Collapse
Affiliation(s)
- Sherin Shaaban
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, United States,ARUP Laboratories, Salt Lake City, Utah, United States,*Correspondence: Sherin Shaaban,
| | - Yuan Ji
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, United States,ARUP Laboratories, Salt Lake City, Utah, United States
| |
Collapse
|
6
|
Elmaadawi AZ, Patel R, Almaaitah Y, Logsdon MG. Effect of pharmacogenomic testing on pediatric mental health outcome: a 6-month follow-up. Pharmacogenomics 2023; 24:73-82. [PMID: 36468359 DOI: 10.2217/pgs-2022-0131] [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: 12/11/2022] Open
Abstract
Aim: This retrospective, case-control study evaluated the effect of pharmacogenomic testing (PGT) on the management of pediatrics with anxiety, major depressive disorder (MDD) and attention-deficit/hyperactivity disorder (ADHD). Methods: The authors examined psychiatric diagnoses, medication histories, CYP450 profiles, SLC6A4, HTR2A, COMT and MTHFR. Results: The authors found no difference in clinical improvement between the two groups. However, the number of medication changes was significantly larger after PGT. The treatment response in MDD and anxiety was not different between the groups, while ADHD treatment response was substantially improved in PGT and correlated with COMT status. Conclusion: PGT had some value with ADHD with doubtful benefit for MDD or anxiety disorders. Accordingly, pediatric indications must be weighed against cost, utility and clinician experience. Limitations included sample size and selection bias.
Collapse
Affiliation(s)
- Ahmed Z Elmaadawi
- Department of Psychiatry, Indiana University School of Medicine-South Bend Campus, Beacon Health System, 707 N. Michigan Street, Suite 400, South Bend, IN 46601, USA
| | - Rikin Patel
- Department of Child & Adolescent Psychiatry, Duke University Medical Center, Durham, NC 27708, USA
| | - Yarob Almaaitah
- Department of Psychiatry, Beacon Medical Group Behavioral Health, 707 N. Michigan Street, South Bend, IN 46601, USA
| | - Matthew G Logsdon
- Internal Medicine Program, University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| |
Collapse
|
7
|
France K, Ammend D, Brown J. Pharmacogenetic Testing and Therapeutic Drug Monitoring Of Sertraline at a Residential Treatment Center for Children and Adolescents: A Pilot Study. Innov Pharm 2022; 13:10.24926/iip.v13i4.5035. [PMID: 37305603 PMCID: PMC10256290 DOI: 10.24926/iip.v13i4.5035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024] Open
Abstract
Background: Sertraline is commonly prescribed to children for the treatment of anxiety and major depressive disorder and is metabolized in part by CYP2C19. While dosing recommendations based on CYP2C19 genotype exist, there is sparse data in children on the relationship between sertraline concentrations and CYP2C19 genotype. Additionally, although rarely utilized in the United States, therapeutic drug monitoring can also help to guide dosing. The primary objective of this pilot study was to compare sertraline concentrations with CYP2C19 genotype. Secondary objectives included exploring the feasibility of using pharmacogenetic testing and therapeutic drug monitoring in a residential treatment center for children and adolescents. Methods: This study was a prospective, open-label study of children prescribed sertraline being treated at a residential treatment center for children and adolescents. Individuals were included if they were < 18 years of age, taking sertraline for at least 2 weeks allowing them to reach steady-state concentrations, being treated through the residential treatment program, and able to understand and speak English. Results: A total of 20 participants (80% female) completed all study procedures, including pharmacogenetic testing and therapeutic drug monitoring, with an average age of 15.4 years (range: 9-17 years). Forty percent (n=8) of participants had a diagnosis of Generalized Anxiety Disorder, while 30% (n=6) had a diagnosis of Major Depressive Disorder. Overall, average sertraline and desmethylsertraline concentrations were 21.1 ng/ml (range: 1-78 ng/ml) and 52.4 ng/ml (range: 1-258 n/ml). Based on CYP2C19 genotypes, 60% (n=12) were normal metabolizers, 10% (n=2) were intermediate metabolizers, and 30% (n=6) were rapid metabolizers. Daily sertraline dose (mg/day) accounted for a significant amount of the observed variability in sertraline (p<0.0001; r2=0.62) and desmethylsertraline concentrations (p<0.001; r2=0.45). When comparing weight-based dosing by sertraline and desmethylsertraline concentrations, sertraline daily dose by weight (mg/kg/day) also accounted for a significant amount of the observed variability in sertraline (p<0.0001; r2=0.60) and desmethylsertraline (p<0.0001; r2=0.59) concentrations. Average daily and weight-based doses for CYP2C19 intermediate, normal, and rapid metabolizers were 75 mg/day, 87.5 mg/day, and 79.2 mg/day and 1.5 mg/kg/day, 1.3 mg/kg/day, and 1.1 mg/kg/day, though these were not significantly different. Conclusion: This small, pilot study showed sertraline dose to be significantly associated with sertraline and desmethylsertraline concentrations. No differences were noted between CYP2C19 metabolizer groups, likely due to the limited sample size. These results also suggest that ordering pharmacogenetic testing and therapeutic drug monitoring in the setting of a child and adolescent residential treatment center is feasible.
Collapse
Affiliation(s)
- Kate France
- University of Minnesota College of Pharmacy, Duluth, Minnesota
| | | | - Jacob Brown
- University of Minnesota College of Pharmacy, Duluth, Minnesota
| |
Collapse
|
8
|
Liu M, Rossow KM, Maxwell-Horn AC, Saucier LA, Van Driest SL. Pediatric considerations for pharmacogenetic selective serotonin reuptake inhibitors clinical decision support. Pharmacotherapy 2022. [PMID: 36524442 DOI: 10.1002/phar.2751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/27/2022] [Accepted: 10/30/2022] [Indexed: 12/23/2022]
Abstract
Pharmacogenetic testing for psychiatry is growing at a rapid pace, with multiple sites utilizing results to help clinical decision-making. Genotype-guided dosing and drug selection have been implemented at several sites, including Vanderbilt University Medical Center, where clinical decision support (CDS) based on pharmacogenetic results went live for selective serotonin reuptake inhibitors in 2020 for both adult and pediatric patients. Effective and appropriate implementation of CYP2D6- and CYP2C19-guided CDS for the pediatric population requires consideration of the evidence for the pharmacogenetic associations, medication indications, and appropriate alternative therapies to be used when a pharmacogenetic contraindication is identified. In this article, we review these pediatric pharmacogenetic considerations for selective serotonin reuptake inhibitor CDS. We include a case study, the current literature supporting clinical recommendations, considerations when designing pediatric CDS, future implications, and examples of sertraline, (es)citalopram, paroxetine, and fluvoxamine alerts.
Collapse
Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katelyn M Rossow
- Developmental-Behavioral Pediatrics, Norton Children's Development Center, Louisville, Kentucky, USA
| | - Angela C Maxwell-Horn
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh Ann Saucier
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
9
|
Schreeck F, Ahne G, Tremmel R, Schaeffeler E, Schwab M. Pharmacogenomics in pediatric medicine and drug development. Pharmacogenomics 2022; 23:709-712. [PMID: 36004680 DOI: 10.2217/pgs-2022-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Filippa Schreeck
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany and University of Tuebingen, Tuebingen, 72074, Germany
| | - Gabriele Ahne
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany and University of Tuebingen, Tuebingen, 72074, Germany.,Department of Paediatrics and Adolescents Medicine, University Hospital Erlangen, Erlangen, 91054, Germany
| | - Roman Tremmel
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany and University of Tuebingen, Tuebingen, 72074, Germany
| | - Elke Schaeffeler
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany and University of Tuebingen, Tuebingen, 72074, Germany
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany and University of Tuebingen, Tuebingen, 72074, Germany.,Departments of Clinical Pharmacology, and Biochemistry and Pharmacy, University of Tuebingen, Tuebingen, 72074, Germany
| |
Collapse
|
10
|
Pépin MA, Otis AS, Tremblay Z, Boulé M, Lebel D, Major P, Lortie A, Pinchefsky E, Rossignol E, Carleton B, Bussières JF, Métras MÉ. Pharmacogenetic testing in pediatric neurology: a pragmatic study evaluating clinician and patient perceptions. Per Med 2022; 19:423-434. [PMID: 35830229 DOI: 10.2217/pme-2021-0150] [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]
Abstract
Aim: To evaluate clinicians' and patients' perceptions of pharmacogenetic testing in a clinical setting. Materials & methods: This is a pragmatic mixed-method prospective observational study. Hospital pharmacists and neurologists participated in focus groups regarding pharmacogenetic testing; patients who received pharmacogenetic testing and their community pharmacists completed surveys to assess their perception of these tests. Results: Most study participants had a positive view of pharmacogenetic testing. Three major themes were identified from the focus groups: receptiveness to pharmacogenetic testing, pharmacogenetic test characteristics and integrating pharmacogenetic tests into practice. Conclusion: The views reported are encouraging for the eventual implementation of pharmacogenetics in practice. Local integration of these tests is an essential step to improve patient care through personalized medicine.
Collapse
Affiliation(s)
- Marie-Anne Pépin
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada
| | - Anne-Sophie Otis
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada
| | - Zoë Tremblay
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada
| | - Marianne Boulé
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada
| | - Denis Lebel
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada
| | - Philippe Major
- Research Center & Division of Neurology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada.,Department of Neuroscience, Université de Montréal, Montréal, Québec, H3T 1J4, Canada.,Department of Pediatrics, Université de Montréal, Montréal, Québec, H3T 1J4, Canada
| | - Anne Lortie
- Research Center & Division of Neurology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada.,Department of Neuroscience, Université de Montréal, Montréal, Québec, H3T 1J4, Canada.,Department of Pediatrics, Université de Montréal, Montréal, Québec, H3T 1J4, Canada
| | - Elana Pinchefsky
- Research Center & Division of Neurology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada.,Department of Neuroscience, Université de Montréal, Montréal, Québec, H3T 1J4, Canada
| | - Elsa Rossignol
- Research Center & Division of Neurology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada.,Department of Neuroscience, Université de Montréal, Montréal, Québec, H3T 1J4, Canada.,Department of Pediatrics, Université de Montréal, Montréal, Québec, H3T 1J4, Canada
| | - Bruce Carleton
- Professor & Division Head, Translational Therapeutics, Department of Pediatrics, University of British-Columbia, Vancouver, British-Columbia, H3T 1J4, Canada.,Director, Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, British-Columbia, V6H 3N1, Canada.,Investigator, BC Children's Hospital Research Institute, Vancouver, British-Columbia, V6H 3N1, Canada
| | - Jean-François Bussières
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada.,Clinical Professor, Faculty of Pharmacy, Université de Montréal, Montréal, Québec, H3T 1J4, Canada
| | - Marie-Élaine Métras
- Pharmacy Practice Research Unit & Department of Pharmacy, CHU Sainte-Justine, Montréal, Québec, H3T 1C5, Canada.,Clinical Professor, Faculty of Pharmacy, Université de Montréal, Montréal, Québec, H3T 1J4, Canada
| |
Collapse
|
11
|
Yalçin N, Flint RB, van Schaik RHN, Simons SHP, Allegaert K. The Impact of Pharmacogenetics on Pharmacokinetics and Pharmacodynamics in Neonates and Infants: A Systematic Review. Pharmgenomics Pers Med 2022; 15:675-696. [PMID: 35795337 PMCID: PMC9252316 DOI: 10.2147/pgpm.s350205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/14/2022] [Indexed: 12/22/2022] Open
Abstract
In neonates, pharmacogenetics has an additional layer of complexity. This is because in addition to genetic variability in genes that code for proteins relevant to clinical pharmacology, there are rapidly maturational changes in these proteins. Consequently, pharmacotherapy in neonates has unique challenges. To provide a contemporary overview on pharmacogenetics in neonates, we conducted a systematic review to identify, describe and quantify the impact of pharmacogenetics on pharmacokinetics and -dynamics in neonates and infants (PROSPERO, CRD42022302029). The search was performed in Medline, Embase, Web of Science and Cochrane, and was extended by a PubMed search on the ‘top 100 Medicines’ (medicine + newborn/infant + pharmacogen*) prescribed to neonates. Following study selection (including data in infants, PGx related) and quality assessment (Newcastle–Ottawa scale, Joanna Briggs Institute tool), 55/789 records were retained. Retained records relate to metabolizing enzymes involved in phase I [cytochrome P450 (CYP1A2, CYP2A6, CYP2B6, CYP2C8/C9/C18, CYP2C19, CYP2D6, CYP3A5, CYP2E1)], phase II [glutathione-S-transferases, N-acetyl transferases, UDP-glucuronosyl-transferase], transporters [ATP-binding cassette transporters, organic cation transporters], or receptor/post-receptor mechanisms [opioid related receptor and post-receptor mechanisms, tumor necrosis factor, mitogen-activated protein kinase 8, vitamin binding protein diplotypes, corticotrophin-releasing hormone receptor-1, nuclear receptor subfamily-1, vitamin K epoxide reductase complex-1, and angiotensin converting enzyme variants]. Based on the available overview, we conclude that the majority of reported pharmacogenetic studies explore and extrapolate observations already described in older populations. Researchers commonly try to quantify the impact of these polymorphisms in small datasets of neonates or infants. In a next step, pharmacogenetic studies in neonatal life should go beyond confirmation of these associations and explore the impact of pharmacogenetics as a covariate limited to maturation of neonatal life (ie, fetal malformations, breastfeeding or clinical syndromes). The challenge is to identify the specific factors, genetic and non-genetic, that contribute to the best benefit/risk balance.
Collapse
Affiliation(s)
- Nadir Yalçin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Correspondence: Karel Allegaert, Neonatal Intensive Care Unit, UZ Leuven, Herestraat 49, Leuven, 3000, Belgium, Tel +32-016-342020, Fax +32-016-343209, Email
| |
Collapse
|
12
|
Berrios C, Sadaro SK, Sandritter T, Wagner JA, Soden S, Black B, Abdel-Rahman S. Parental understanding and attitudes following pharmacogenomic testing for pediatric neuropsychiatric patients. Pharmacogenomics 2022; 23:345-354. [DOI: 10.2217/pgs-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study explores parental understanding and attitudes around pharmacogenomic results in their child(ren). Patients and methods: In-depth interviews with parents whose child(ren) had received a pharmacogenomic testing panel for management of neuropsychiatric medications were completed. Interviews were analyzed for themes and accuracy of understanding of results. Results: In 18 parents interviewed, 49/63 (78%) of statements made regarding results were accurate. Differences in understanding were seen by clinic, number of medications and result type. Parents expected results to guide prescribing and perceived the greatest utility in results that could impact current care. Results predicting normal drug metabolism may create mixed feelings. Conclusion: Parents perceive utility in pharmacogenomic testing for their children. Challenges exist in understanding probabilistic and multifactorial information about pharmacogenomic results.
Collapse
Affiliation(s)
- Courtney Berrios
- Genomic Medicine Center, Children's Mercy, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Sophia K Sadaro
- Genomic Medicine Center, Children's Mercy, Kansas City, MO 64108, USA
| | - Tracy Sandritter
- Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy, Kansas City, MO 64108, USA
- School of Pharmacy, University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Jennifer A Wagner
- School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
- Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy, Kansas City, MO 64108, USA
| | - Sarah Soden
- School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
- Developmental & Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, USA
| | - Benjamin Black
- The Thompson Center for Autism & Neurodevelopmental Disorders, University of Missouri, Columbia, MO 65201, USA
| | - Susan Abdel-Rahman
- Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy, Kansas City, MO 64108, USA
- School of Pharmacy, University of Missouri Kansas City, Kansas City, MO 64108, USA
| |
Collapse
|
13
|
Barker CIS, Groeneweg G, Maitland-van der Zee AH, Rieder MJ, Hawcutt DB, Hubbard TJ, Swen JJ, Carleton BC. Pharmacogenomic testing in paediatrics: clinical implementation strategies. Br J Clin Pharmacol 2021; 88:4297-4310. [PMID: 34907575 PMCID: PMC9544158 DOI: 10.1111/bcp.15181] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/27/2022] Open
Abstract
Pharmacogenomics (PGx) relates to the study of genetic factors determining variability in drug response. Implementing PGx testing in paediatric patients can enhance drug safety, helping to improve drug efficacy or reduce the risk of toxicity. Despite its clinical relevance, the implementation of PGx testing in paediatric practice to date has been variable and limited. As with most paediatric pharmacological studies, there are well‐recognised barriers to obtaining high‐quality PGx evidence, particularly when patient numbers may be small, and off‐label or unlicensed prescribing remains widespread. Furthermore, trials enrolling small numbers of children can rarely, in isolation, provide sufficient PGx evidence to change clinical practice, so extrapolation from larger PGx studies in adult patients, where scientifically sound, is essential. This review paper discusses the relevance of PGx to paediatrics and considers implementation strategies from a child health perspective. Examples are provided from Canada, the Netherlands and the UK, with consideration of the different healthcare systems and their distinct approaches to implementation, followed by future recommendations based on these cumulative experiences. Improving the evidence base demonstrating the clinical utility and cost‐effectiveness of paediatric PGx testing will be critical to drive implementation forwards. International, interdisciplinary collaborations will enhance paediatric data collation, interpretation and evidence curation, while also supporting dedicated paediatric PGx educational initiatives. PGx consortia and paediatric clinical research networks will continue to play a central role in the streamlined development of effective PGx implementation strategies to help optimise paediatric pharmacotherapy.
Collapse
Affiliation(s)
- Charlotte I S Barker
- Department of Medical & Molecular Genetics, King's College London, London, UK.,Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gabriella Groeneweg
- Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.,Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Anke H Maitland-van der Zee
- Respiratory Medicine/Pediatric Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Michael J Rieder
- Departments of Paediatrics, Physiology and Pharmacology and Medicine, Western University, London, Ontario, Canada.,Molecular Medicine Group, Robarts Research Institute, London, Ontario, Canada
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.,NIHR Clinical Research Facility, Alder Hey Children's Hospital, Liverpool, UK
| | - Tim J Hubbard
- Department of Medical & Molecular Genetics, King's College London, London, UK.,Genomics England, London, UK
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalized Therapeutics, Leiden, The Netherlands
| | - Bruce C Carleton
- Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.,Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| |
Collapse
|
14
|
Cacabelos R, Naidoo V, Corzo L, Cacabelos N, Carril JC. Genophenotypic Factors and Pharmacogenomics in Adverse Drug Reactions. Int J Mol Sci 2021; 22:ijms222413302. [PMID: 34948113 PMCID: PMC8704264 DOI: 10.3390/ijms222413302] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
Adverse drug reactions (ADRs) rank as one of the top 10 leading causes of death and illness in developed countries. ADRs show differential features depending upon genotype, age, sex, race, pathology, drug category, route of administration, and drug–drug interactions. Pharmacogenomics (PGx) provides the physician effective clues for optimizing drug efficacy and safety in major problems of health such as cardiovascular disease and associated disorders, cancer and brain disorders. Important aspects to be considered are also the impact of immunopharmacogenomics in cutaneous ADRs as well as the influence of genomic factors associated with COVID-19 and vaccination strategies. Major limitations for the routine use of PGx procedures for ADRs prevention are the lack of education and training in physicians and pharmacists, poor characterization of drug-related PGx, unspecific biomarkers of drug efficacy and toxicity, cost-effectiveness, administrative problems in health organizations, and insufficient regulation for the generalized use of PGx in the clinical setting. The implementation of PGx requires: (i) education of physicians and all other parties involved in the use and benefits of PGx; (ii) prospective studies to demonstrate the benefits of PGx genotyping; (iii) standardization of PGx procedures and development of clinical guidelines; (iv) NGS and microarrays to cover genes with high PGx potential; and (v) new regulations for PGx-related drug development and PGx drug labelling.
Collapse
Affiliation(s)
- Ramón Cacabelos
- Department of Genomic Medicine, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain
- Correspondence: ; Tel.: +34-981-780-505
| | - Vinogran Naidoo
- Department of Neuroscience, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Lola Corzo
- Department of Medical Biochemistry, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Natalia Cacabelos
- Department of Medical Documentation, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Juan C. Carril
- Departments of Genomics and Pharmacogenomics, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| |
Collapse
|
15
|
The Utility of Pharmacogenetic-Guided Psychotropic Medication Selection for Pediatric Patients: A Retrospective Study. Pediatr Rep 2021; 13:421-433. [PMID: 34449718 PMCID: PMC8396342 DOI: 10.3390/pediatric13030049] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND To describe trends and clinical experiences in applying commercial pharmacogenetic testing among pediatric patients with neuropsychiatric disorders. METHODS Demographic and clinical data of patients receiving GeneSight® testing from January 2015 to November 2016 at an urban pediatric hospital were retrospectively extracted from medical charts. Outcome data included pharmacogenetic test results and medication prescriptions before and after the test. RESULTS A total of 450 patients (12.1 ± 4.3 years) diagnosed with anxiety disorder, attention deficit hyperactivity disorder, developmental disorders including autism, and/or a mood disorder received testing, and 435 of them were prescribed medications. Comparing data before and after testing, the total number of psychotropic prescriptions were reduced by 27.2% and the number of prescribed medications with severe gene-drug interactions decreased from 165 to 95 (11.4% to 8.9% of total medications prescribed). Approximately 40% of actionable genetic annotation were related to CYP2CD6 and CYP2C19. Patients of Asian descent had significantly higher likelihood than other races of being classified as poor to intermediate metabolizers of antidepressants, mood stabilizers, and antipsychotics (p = 0.008, 0.007, and 0.001, respectively). Diagnoses, including autism spectrum disorder, were not associated with increased risks of severe gene-drug interactions. CONCLUSIONS Pharmacogenetic testing in child and adolescent psychiatry is currently based on few clinically actionable genes validated by CPIC and/or FDA. Although this approach can be moderately utilized to guide psychotropic medication prescribing for pediatric patients with psychiatric disorders, clinicians should cautiously interpret test results while still relying on clinical experience and judgment to direct the final selection of medication.
Collapse
|
16
|
Hoshitsuki K, Fernandez CA, Yang JJ. Pharmacogenomics for Drug Dosing in Children: Current Use, Knowledge, and Gaps. J Clin Pharmacol 2021; 61 Suppl 1:S188-S192. [PMID: 34185912 DOI: 10.1002/jcph.1891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/29/2021] [Indexed: 11/08/2022]
Abstract
Pharmacogenomics research ranges from the discovery of genetic factors to explain interpatient variability in drug exposure and response to clinical implementation of this knowledge to improve pharmacotherapy. Medications with actionable pharmacogenomic associations are frequently used in children, and therefore pharmacogenomics-guided precision medicine is readily applicable to the pediatric population. Although heritable genetics are considered immutable, the impact of genetic variation in pharmacogenes is modified by other factors such as age-dependent changes in gene expression. Early evidence has emerged indicating that the interaction between ontogeny and pharmacogenomics determines whether or how genetics-based dosing algorithms should be adjusted in children versus adults. However, there is still a paucity of data describing pharmacogenomic associations in patient populations across the life span. Future research is much needed to evaluate the impact of pharmacogenomics on drug dosing specific to the pediatric population, along with consideration of other developmental and physiological factors uniquely related to drug disposition in this population.
Collapse
Affiliation(s)
- Keito Hoshitsuki
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian A Fernandez
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| |
Collapse
|
17
|
Implementing Pharmacogenomics Testing: Single Center Experience at Arkansas Children's Hospital. J Pers Med 2021; 11:jpm11050394. [PMID: 34064668 PMCID: PMC8150685 DOI: 10.3390/jpm11050394] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 02/07/2023] Open
Abstract
Pharmacogenomics (PGx) is a growing field within precision medicine. Testing can help predict adverse events and sub-therapeutic response risks of certain medications. To date, the US FDA lists over 280 drugs which provide biomarker-based dosing guidance for adults and children. At Arkansas Children’s Hospital (ACH), a clinical PGx laboratory-based test was developed and implemented to provide guidance on 66 pediatric medications for genotype-guided dosing. This PGx test consists of 174 single nucleotide polymorphisms (SNPs) targeting 23 clinically actionable PGx genes or gene variants. Individual genotypes are processed to provide per-gene discrete results in star-allele and phenotype format. These results are then integrated into EPIC- EHR. Genomic indicators built into EPIC-EHR provide the source for clinical decision support (CDS) for clinicians, providing genotype-guided dosing.
Collapse
|
18
|
Cohn I, Manshaei R, Liston E, Okello JBA, Khan R, Curtis MR, Krupski AJ, Jobling RK, Kalbfleisch K, Paton TA, Reuter MS, Hayeems RZ, Verstegen RHJ, Goldman A, Kim RH, Ito S. Assessment of the Implementation of Pharmacogenomic Testing in a Pediatric Tertiary Care Setting. JAMA Netw Open 2021; 4:e2110446. [PMID: 34037732 PMCID: PMC8155824 DOI: 10.1001/jamanetworkopen.2021.10446] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Pharmacogenomic (PGx) testing provides preemptive pharmacotherapeutic guidance regarding the lack of therapeutic benefit or adverse drug reactions of PGx targeted drugs. Pharmacogenomic information is of particular value among children with complex medical conditions who receive multiple medications and are at higher risk of developing adverse drug reactions. OBJECTIVES To assess the implementation outcomes of a PGx testing program comprising both a point-of-care model that examined targeted drugs and a preemptive model informed by whole-genome sequencing that evaluated a broad range of drugs for potential therapy among children in a pediatric tertiary care setting. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted at The Hospital for Sick Children in Toronto, Ontario, from January 2017 to September 2020. Pharmacogenomic analyses were performed among 172 children who were categorized into 2 groups: a point-of-care cohort and a preemptive cohort. The point-of-care cohort comprised 57 patients referred to the consultation clinic for planned therapy with PGx targeted drugs and/or for adverse drug reactions, including lack of therapeutic benefit, after the receipt of current or past medications. The preemptive cohort comprised 115 patients who received exploratory whole-genome sequencing-guided PGx testing for their heart conditions from the cardiac genome clinic at the Ted Rogers Centre for Heart Research. EXPOSURES Patients received PGx analysis of whole-genome sequencing data and/or multiplex genotyping of 6 pharmacogenes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, VKORC1, and TPMT) that have established PGx clinical guidelines. MAIN OUTCOMES AND MEASURES The number of patients for whom PGx test results warranted deviation from standard dosing regimens. RESULTS A total of 172 children (mean [SD] age, 8.5 [5.6] years; 108 boys [62.8%]) were enrolled in the study. In the point-of-care cohort, a median of 2 target genes (range, 1-5 genes) were investigated per individual, with CYP2C19 being the most frequently examined; genotypes in 21 of 57 children (36.8%) were incompatible with standard treatment regimens. As expected from population allelic frequencies, among the 115 children in the whole-genome sequencing-guided preemptive cohort, 92 children (80.0%) were recommended to receive nonstandard treatment regimens for potential drug therapies based on their 6-gene pharmacogenetic profile. CONCLUSIONS AND RELEVANCE In this cohort study, among both the point-of-care and preemptive cohorts, the multiplex PGx testing program provided dosing recommendations that deviated from standard regimens at an overall rate that was similar to the population frequencies of relevant variants.
Collapse
Affiliation(s)
- Iris Cohn
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roozbeh Manshaei
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eriskay Liston
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John B. A. Okello
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reem Khan
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Meredith R. Curtis
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abby J. Krupski
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rebekah K. Jobling
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Genome Diagnostics, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kelsey Kalbfleisch
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tara A. Paton
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Miriam S. Reuter
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Canada’s Genomic Enterprise (CGEn), The Hospital for Sick Children, Toronto, Ontario, Canada
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robin Z. Hayeems
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ruud H. J. Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Raymond H. Kim
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Micaglio E, Locati ET, Monasky MM, Romani F, Heilbron F, Pappone C. Role of Pharmacogenetics in Adverse Drug Reactions: An Update towards Personalized Medicine. Front Pharmacol 2021; 12:651720. [PMID: 33995067 PMCID: PMC8120428 DOI: 10.3389/fphar.2021.651720] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/29/2021] [Indexed: 12/28/2022] Open
Abstract
Adverse drug reactions (ADRs) are an important and frequent cause of morbidity and mortality. ADR can be related to a variety of drugs, including anticonvulsants, anaesthetics, antibiotics, antiretroviral, anticancer, and antiarrhythmics, and can involve every organ or apparatus. The causes of ADRs are still poorly understood due to their clinical heterogeneity and complexity. In this scenario, genetic predisposition toward ADRs is an emerging issue, not only in anticancer chemotherapy, but also in many other fields of medicine, including hemolytic anemia due to glucose-6-phosphate dehydrogenase (G6PD) deficiency, aplastic anemia, porphyria, malignant hyperthermia, epidermal tissue necrosis (Lyell's Syndrome and Stevens-Johnson Syndrome), epilepsy, thyroid diseases, diabetes, Long QT and Brugada Syndromes. The role of genetic mutations in the ADRs pathogenesis has been shown either for dose-dependent or for dose-independent reactions. In this review, we present an update of the genetic background of ADRs, with phenotypic manifestations involving blood, muscles, heart, thyroid, liver, and skin disorders. This review aims to illustrate the growing usefulness of genetics both to prevent ADRs and to optimize the safe therapeutic use of many common drugs. In this prospective, ADRs could become an untoward "stress test," leading to new diagnosis of genetic-determined diseases. Thus, the wider use of pharmacogenetic testing in the work-up of ADRs will lead to new clinical diagnosis of previously unsuspected diseases and to improved safety and efficacy of therapies. Improving the genotype-phenotype correlation through new lab techniques and implementation of artificial intelligence in the future may lead to personalized medicine, able to predict ADR and consequently to choose the appropriate compound and dosage for each patient.
Collapse
Affiliation(s)
- Emanuele Micaglio
- Arrhythmology and Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Emanuela T Locati
- Arrhythmology and Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Michelle M Monasky
- Arrhythmology and Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Federico Romani
- Arrhythmology and Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy.,Vita-Salute San Raffaele University, (Vita-Salute University) for Federico Romani, Milan, Italy
| | | | - Carlo Pappone
- Arrhythmology and Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy.,Vita-Salute San Raffaele University, (Vita-Salute University) for Federico Romani, Milan, Italy
| |
Collapse
|
20
|
Liko I, Lee YM, Stutzman DL, Blackmer AB, Deininger KM, Reynolds AM, Aquilante CL. Providers' perspectives on the clinical utility of pharmacogenomic testing in pediatric patients. Pharmacogenomics 2021; 22:263-274. [PMID: 33657875 DOI: 10.2217/pgs-2020-0112] [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: 02/06/2023] Open
Abstract
Aim: To assess providers' knowledge, attitudes, perceptions, and experiences related to pharmacogenomic (PGx) testing in pediatric patients. Materials & methods: An electronic survey was sent to multidisciplinary healthcare providers at a pediatric hospital. Results: Of 261 respondents, 71.3% were slightly or not at all familiar with PGx, despite 50.2% reporting prior PGx education or training. Most providers, apart from psychiatry, perceived PGx to be at least moderately useful to inform clinical decisions. However, only 26.4% of providers had recent PGx testing experience. Unfamiliarity with PGx and uncertainty about the clinical value of testing were common perceived challenges. Conclusion: Low PGx familiarity among pediatric providers suggests additional education and electronic resources are needed for PGx examples in which data support testing in children.
Collapse
Affiliation(s)
- Ina Liko
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Yee Ming Lee
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Danielle L Stutzman
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA.,Department of Pharmacy, Children's Hospital Colorado, Aurora, CO 80045, USA.,Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Allison B Blackmer
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA.,Department of Pharmacy, Children's Hospital Colorado, Aurora, CO 80045, USA.,Special Care Clinic, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Ann M Reynolds
- Special Care Clinic, Children's Hospital Colorado, Aurora, CO 80045, USA.,Department of Pediatrics, University of Colorado School of Medicine & Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| |
Collapse
|