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Santenna C, Shubham A, Ratinder J, Abhijit R, Tamonud M, Jitendra S, Shamim MA, Balakrishnan S. Drug metabolizing enzymes pharmacogenetic variation-informed antidepressant therapy approach for common mental disorders: A systematic review and meta-analysis. J Affect Disord 2024; 367:832-844. [PMID: 39265864 DOI: 10.1016/j.jad.2024.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 08/22/2024] [Accepted: 09/08/2024] [Indexed: 09/14/2024]
Abstract
IMPORTANCE Currently, 30-50 % of individuals with depression and 40 % with anxiety-collectively referred to as common mental disorders (CMDs), exhibit inadequate responses to antidepressant treatments. OBJECTIVE To assess the effectiveness and safety of drug-metabolizing enzyme pharmacogenetic variation informed treatment (PGxIT) versus usual antidepressant treatment (UT) in patients with CMDs. DATA SOURCES A literature search was conducted in the MEDLINE, Scopus, and Cochrane Library databases from inception until January 30, 2024. STUDY SELECTION Studies were selected based on CMD diagnoses, reporting on the genetic variations of drug-metabolizing enzyme (DME) genes in relation to antidepressants, involving PGxIT and UT groups with human subjects, and published in English. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were performed independently by two authors. A pooled risk ratio (RR) with 95 % CI was estimated using both random and fixed-effect models, and heterogeneity was assessed using Cochran's Q test and the I2 statistic. The publication bias of eligible studies was assessed using post hoc Doi plots and the LFK index. RESULTS This systematic review included 18 studies (n = 7021). The PGxIT demonstrated greater efficacy in the remission of symptoms of depressive disorder at 8 weeks (RR 1.523 [95 % CI: 1.255-1.843]; I2 = 48 %) and 12 weeks (RR 1.631 [95 % CI: 1.001-2.657]; I2 = 86 %; p < 0.01), and symptoms of anxiety disorder compared to UT. Additionally, the risk of adverse drug events (ADEs) was significantly lower in the PGxIT group (RR = 0.65 [95 % CI: 0.52-0.82]; I2 = 0 %) than in the UT group. The certainty of evidence for both outcomes was moderate. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis suggest that pharmacogenetically guided antidepressant treatment, based on genetic variation in drug-metabolizing enzymes, is associated with superior efficacy in the remission of symptoms for patients with depressive disorders and a reduction in ADEs compared to usual treatment and the findings of the systematic review for remission in anxiety disorders indicate that, PGx guided treatment is also associated with increased remission of symptoms in anxiety disorders compared to usual treatment.
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Affiliation(s)
- Chenchula Santenna
- Department of Pharmacology, All India Institute of Medical Sciences-Bhopal, Madhya Pradesh 462020, India.
| | - Atal Shubham
- Department of Pharmacology, All India Institute of Medical Sciences-Bhopal, Madhya Pradesh 462020, India
| | - Jhaj Ratinder
- Department of Pharmacology, All India Institute of Medical Sciences-Bhopal, Madhya Pradesh 462020, India
| | - Rozatkar Abhijit
- Department of Psychiatry, All India Institute of Medical Sciences-Bhopal, Bhopal 462020, India
| | - Modak Tamonud
- Department of Psychiatry, All India Institute of Medical Sciences-Bhopal, Bhopal 462020, India
| | - Singh Jitendra
- Department of Translational Medicine(,) All India Institute of Medical Sciences-Bhopal, Bhopal 462020, India
| | - Muhammad Aaqib Shamim
- Department of Pharmacology, All India Institute of Medical Sciences - Jodhpur, Jodhpur 342005, India
| | - S Balakrishnan
- Department of Pharmacology, All India Institute of Medical Sciences-Bhopal, Madhya Pradesh 462020, India
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Ioannou KI, Constantinidou A, Chatzittofis A. Genetic testing in psychiatry, the perceptions of healthcare workers and patients: a mini review. Front Public Health 2024; 12:1466585. [PMID: 39450380 PMCID: PMC11499203 DOI: 10.3389/fpubh.2024.1466585] [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: 07/19/2024] [Accepted: 09/25/2024] [Indexed: 10/26/2024] Open
Abstract
Background Genetic testing in psychiatry has gained attention, raising questions about its application and impact. Understanding stakeholders' perspectives, including healthcare providers and patients, is vital for informed policy development. The aim of this systematic review was to focus on the perceptions and concerns of patients and healthcare workers in psychiatry regarding the use of genetic testing. Methods We conducted a systematic review following PRISMA guidelines, for the period 1/2/2014, to 1/1/2024, via PubMed and Embase databases identifying 50 articles in total. After excluding duplicates (n = 12), 38 articles went through screening. After careful full-text article assessment for eligibility and applying the inclusion and exclusion criteria, only fifteen (n = 15) of the articles were included. Results Among 15 selected studies involving 3,156 participants (2,347 healthcare professionals; 809 patients), thematic analysis identified four primary themes: Organizational-implementation concerns, Ethical Considerations, Concerns on changes in clinical praxis, and Legal implications. Despite these concerns, seven out of eleven studies indicated that healthcare workers viewed genetic testing in psychiatry positively. Patients' perspectives varied, with two of the four studies reflecting positive attitudes. No pervasive negative sentiment was observed. Conclusion Our review highlights the multidimensional perspectives of healthcare professionals and patients surrounding the application of genetic testing in psychiatry. These considerations need to be addressed to facilitate the implementation of genetic testing in clinical praxis in psychiatry. Further research is needed for validation of the results and to guide policies and clinicians in the integration of genetic testing into mental healthcare practice.
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Affiliation(s)
| | | | - Andreas Chatzittofis
- Medical School, University of Cyprus, Nicosia, Cyprus
- Department of Clinical Sciences and Psychiatry, Umeå University, Umeå, Sweden
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Jameson A, Tomlinson J, Medlinskiene K, Howard D, Saeed I, Sohal J, Dalton C, Sagoo GS, Cardno A, Bristow GC, Fylan B, McLean SL. Normalising the Implementation of Pharmacogenomic (PGx) Testing in Adult Mental Health Settings: A Theory-Based Systematic Review. J Pers Med 2024; 14:1032. [PMID: 39452539 PMCID: PMC11508855 DOI: 10.3390/jpm14101032] [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: 08/15/2024] [Revised: 09/13/2024] [Accepted: 09/18/2024] [Indexed: 10/26/2024] Open
Abstract
Pharmacogenomic (PGx) testing can help personalise psychiatric prescribing and improve on the currently adopted trial-and-error prescribing approach. However, widespread implementation is yet to occur. Understanding factors influencing implementation is pertinent to the psychiatric PGx field. Normalisation Process Theory (NPT) seeks to understand the work involved during intervention implementation and is used by this review (PROSPERO: CRD42023399926) to explore factors influencing PGx implementation in psychiatry. Four databases were systematically searched for relevant records and assessed for eligibility following PRISMA guidance. The QuADS tool was applied during quality assessment of included records. Using an abductive approach to codebook thematic analysis, barrier and facilitator themes were developed using NPT as a theoretical framework. Twenty-nine records were included in the data synthesis. Key barrier themes included a PGx knowledge gap, a lack of consensus in policy and guidance, and uncertainty towards the use of PGx. Facilitator themes included an interest in PGx use as a new and improved approach to prescribing, a desire for a multidisciplinary approach to PGx implementation, and the importance of fostering a climate for PGx implementation. Using NPT, this novel review systematically summarises the literature in the psychiatric PGx implementation field. The findings highlight a need to develop national policies on using PGx, and an education and training workforce plan for mental health professionals. By understanding factors influencing implementation, the findings help to address the psychiatric PGx implementation gap. This helps move clinical practice closer towards a personalised psychotropic prescribing approach and associated improvements in patient outcomes. Future policy and research should focus on the appraisal of PGx implementation in psychiatry and the role of pharmacists in PGx service design, implementation, and delivery.
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Affiliation(s)
- Adam Jameson
- Bradford District Care NHS Foundation Trust, Bradford BD18 3LD, UK
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
- Wolfson Centre for Applied Health Research, Bradford BD9 6RJ, UK
| | - Justine Tomlinson
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Kristina Medlinskiene
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
- Pharmacy Department, Hull University Teaching Hospitals NHS Trust, Hull HU3 2JZ, UK
| | - Dane Howard
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
- Leeds Teaching Hospitals NHS Foundation Trust, Leeds LS9 7TF, UK
| | - Imran Saeed
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
- Leeds Teaching Hospitals NHS Foundation Trust, Leeds LS9 7TF, UK
| | - Jaspreet Sohal
- Bradford District Care NHS Foundation Trust, Bradford BD18 3LD, UK
| | - Caroline Dalton
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield S1 1WB, UK
| | - Gurdeep S. Sagoo
- Population Health Sciences Institute, Newcastle University, Newcastle NE2 4HH, UK
| | - Alastair Cardno
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9LH, UK
| | - Greg C. Bristow
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Beth Fylan
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
- Wolfson Centre for Applied Health Research, Bradford BD9 6RJ, UK
- NIHR Yorkshire & Humber Patient Safety Research Collaboration, Bradford BD9 6RJ, UK
| | - Samantha L. McLean
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
- Wolfson Centre for Applied Health Research, Bradford BD9 6RJ, UK
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Ewasiuk E, Emery J, Reid G, Saya S. Implementing pharmacogenomic testing in Australian general practice: an exploratory qualitative study. Pharmacogenomics 2024; 25:377-389. [PMID: 39109497 PMCID: PMC11418283 DOI: 10.1080/14622416.2024.2382078] [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: 03/22/2024] [Accepted: 07/12/2024] [Indexed: 09/21/2024] Open
Abstract
Aim: To explore general practitioners' (GPs) views on implementing pharmacogenomic testing in Australian general practice.Methods: Semi-structured interviews were conducted with nine GPs in Australia, recruited from primary care networks. Interviews were analyzed using thematic analysis. Themes were mapped onto the Consolidated Framework for Implementation Research domains.Results: Barriers to implementation included lack of knowledge, education, standardized pharmacogenomic reports and national clinical guidelines and financial inaccessibility. Facilitators included positive exposure to pharmacogenomics, peer influences, interdisciplinary collaboration and proven clinical utility. Current uptake was minimal; however, GPs shared positive perceptions of clinical use.Conclusion: Recommendations for successful implementation include building and disseminating clinical evidence, developing national guidelines and standardized reports, incorporation into formal education and increasing financial accessibility.
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Affiliation(s)
- Emma Ewasiuk
- Department of Paediatrics, University of Melbourne, Melbourne, 3010, Australia
| | - Jon Emery
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, 3010, Australia
- Center for Cancer Research, University of Melbourne,Melbourne, 3000, Australia
| | - Gabrielle Reid
- Department of Paediatrics, University of Melbourne, Melbourne, 3010, Australia
| | - Sibel Saya
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, 3010, Australia
- Center for Cancer Research, University of Melbourne,Melbourne, 3000, Australia
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Rajkumar RP. The Advantages of Combining Therapies in Treating Psychiatric Patients. Brain Sci 2024; 14:708. [PMID: 39061448 PMCID: PMC11274852 DOI: 10.3390/brainsci14070708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Mental illnesses are among the leading causes of morbidity and disability worldwide, and the burden associated with these disorders has increased steadily over the past three decades [...].
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Affiliation(s)
- Ravi Philip Rajkumar
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India
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Tesfamicael KG, Zhao L, Fernández-Rodríguez R, Adelson DL, Musker M, Polasek TM, Lewis MD. Efficacy and safety of pharmacogenomic-guided antidepressant prescribing in patients with depression: an umbrella review and updated meta-analysis. Front Psychiatry 2024; 15:1276410. [PMID: 39086729 PMCID: PMC11289719 DOI: 10.3389/fpsyt.2024.1276410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 06/26/2024] [Indexed: 08/02/2024] Open
Abstract
Aim To determine the efficacy and safety of pharmacogenomics (PGx)-guided antidepressant prescribing in patients with depression through an umbrella review and updated meta-analysis. Methods A comprehensive systematic search was conducted on PsycINFO, PubMed, Embase and the Cochrane databases. The pooled effect sizes of randomized controlled trials (RCTs) were expressed as mean differences for continuous data and risk ratios for noncontinuous data. Results Patients who received PGx-guided medications were 41% to 78% more likely to achieve remission and 20% to 49% more likely to respond to antidepressants than patients receiving treatment-as-usual (TAU). Conclusion PGx-guided antidepressant prescribing improves the treatment of depression. However, the significance and magnitude of the benefit varies widely between studies and different PGx testing panels. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022321324.
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Affiliation(s)
- Kiflu G. Tesfamicael
- School of Biological Sciences, University of Adelaide, Adelaide, SA, Australia
- Lifelong Health, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Lijun Zhao
- Lifelong Health, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | | | - David L. Adelson
- School of Biological Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Michael Musker
- Adelaide Nursing School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas M. Polasek
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
| | - Martin David Lewis
- School of Biological Sciences, University of Adelaide, Adelaide, SA, Australia
- Lifelong Health, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
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Ghanbarian S, Wong GWK, Bunka M, Edwards L, Cressman S, Conte T, Peterson S, Vijh R, Price M, Schuetz C, Erickson D, Riches L, Landry G, McGrail K, Austin J, Bryan S. A Canadian Simulation Model for Major Depressive Disorder: Study Protocol. PHARMACOECONOMICS - OPEN 2024; 8:493-505. [PMID: 38528312 PMCID: PMC11058136 DOI: 10.1007/s41669-024-00481-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Major depressive disorder (MDD) is a common, often recurrent condition and a significant driver of healthcare costs. People with MDD often receive pharmacological therapy as the first-line treatment, but the majority of people require more than one medication trial to find one that relieves symptoms without causing intolerable side effects. There is an acute need for more effective interventions to improve patients' remission and quality of life and reduce the condition's economic burden on the healthcare system. Pharmacogenomic (PGx) testing could deliver these objectives, using genomic information to guide prescribing decisions. With an already complex and multifaceted care pathway for MDD, future evaluations of new treatment options require a flexible analytic infrastructure encompassing the entire care pathway. Individual-level simulation models are ideally suited for this purpose. We sought to develop an economic simulation model to assess the effectiveness and cost effectiveness of PGx testing for individuals with major depression. Additionally, the model serves as an analytic infrastructure, simulating the entire patient pathway for those with MDD. METHODS AND ANALYSIS Key stakeholders, including patient partners, clinical experts, researchers, and modelers, designed and developed a discrete-time microsimulation model of the clinical pathways of adults with MDD in British Columbia (BC), including all publicly-funded treatment options and multiple treatment steps. The Simulation Model of Major Depression (SiMMDep) was coded with a modular approach to enhance flexibility. The model was populated using multiple original data analyses conducted with BC administrative data, a systematic review, and an expert panel. The model accommodates newly diagnosed and prevalent adult patients with MDD in BC, with and without PGx-guided treatment. SiMMDep comprises over 1500 parameters in eight modules: entry cohort, demographics, disease progression, treatment, adverse events, hospitalization, costs and quality-adjusted life-years (payoff), and mortality. The model predicts health outcomes and estimates costs from a health system perspective. In addition, the model can incorporate interactive decision nodes to address different implementation strategies for PGx testing (or other interventions) along the clinical pathway. We conducted various forms of model validation (face, internal, and cross-validity) to ensure the correct functioning and expected results of SiMMDep. CONCLUSION SiMMDep is Canada's first medication-specific, discrete-time microsimulation model for the treatment of MDD. With patient partner collaboration guiding its development, it incorporates realistic care journeys. SiMMDep synthesizes existing information and incorporates provincially-specific data to predict the benefits and costs associated with PGx testing. These predictions estimate the effectiveness, cost-effectiveness, resource utilization, and health gains of PGx testing compared with the current standard of care. However, the flexible analytic infrastructure can be adapted to support other policy questions and facilitate the rapid synthesis of new data for a broader search for efficiency improvements in the clinical field of depression.
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Affiliation(s)
- Shahzad Ghanbarian
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
| | - Gavin W K Wong
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mary Bunka
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Louisa Edwards
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Sonya Cressman
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Tania Conte
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Rohit Vijh
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Morgan Price
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Christian Schuetz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - David Erickson
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
- Psychology Department, Fraser Health, Vancouver, BC, Canada
| | | | | | - Kim McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Jehannine Austin
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada
| | - Stirling Bryan
- School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Kharasch ED, Lenze EJ. Pharmacogenetic Influence on Stereoselective Steady-State Disposition of Bupropion. Drug Metab Dispos 2024; 52:455-466. [PMID: 38467432 PMCID: PMC11023817 DOI: 10.1124/dmd.124.001697] [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] [Received: 02/17/2024] [Revised: 03/02/2024] [Accepted: 03/07/2024] [Indexed: 03/13/2024] Open
Abstract
Bupropion is used for treating depression, obesity, and seasonal affective disorder, and for smoking cessation. Bupropion is commonly prescribed, but has complex pharmacokinetics and interindividual variability in metabolism and bioactivation may influence therapeutic response, tolerability, and safety. Bupropion is extensively and stereoselectively metabolized, the metabolites are pharmacologically active, and allelic variation in cytochrome P450 (CYP) 2B6 affects clinical hydroxylation of single-dose bupropion. Genetic effects on stereoselective disposition of steady-state bupropion are not known. In this preplanned secondary analysis of a prospective, randomized, double-blinded, crossover study which compared brand and generic bupropion XL 300 mg drug products, we measured steady-state enantiomeric plasma and urine parent bupropion and primary and secondary metabolite concentrations. This investigation evaluated the influence of genetic polymorphisms in CYP2B6, CYP2C19, and P450 oxidoreductase on the disposition of Valeant Pharmaceuticals Wellbutrin brand bupropion in 67 participants with major depressive disorder. We found that hydroxylation of both bupropion enantiomers was lower in carriers of the CYP2B6*6 allele and in carriers of the CYP2B6 516G>T variant, with correspondingly greater bupropion and lesser hydroxybupropion plasma concentrations. Hydroxylation was 25-50% lower in CYP2B6*6 carriers and one-third to one-half less in 516T carriers. Hydroxylation of the bupropion enantiomers was comparably affected by CYP2B6 variants. CYP2C19 polymorphisms did not influence bupropion plasma concentrations or hydroxybupropion formation but did influence the minor pathway of 4'-hydroxylation of bupropion and primary metabolites. P450 oxidoreductase variants did not influence bupropion disposition. Results show that CYP2B6 genetic variants affect steady-state metabolism and bioactivation of Valeant brand bupropion, which may influence therapeutic outcomes. SIGNIFICANCE STATEMENT: Bupropion, used for depression, obesity, and smoking cessation, undergoes metabolic bioactivation, with incompletely elucidated interindividual variability. We evaluated cytochrome P450 (CYP) 2B6, CYP2C19 and P450 oxidoreductase genetic variants and steady-state bupropion and metabolite enantiomers disposition. Both enantiomers hydroxylation was lower in CYP2B6*6 and CYP2B6 516G>T carriers, with greater bupropion and lesser hydroxybupropion plasma concentrations. CYP2C19 polymorphisms did not affect bupropion or hydroxybupropion but did influence minor 4'-hydroxylation of bupropion and primary metabolites. CYP2B6 variants affect steady-state bupropion bioactivation, which may influence therapeutic outcomes.
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Affiliation(s)
- Evan D Kharasch
- Department of Anesthesiology, Duke University, Durham, North Carolina (E.D.K.); Bermaride, LLC (E.D.K.); and Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri (E.J.L.)
| | - Eric J Lenze
- Department of Anesthesiology, Duke University, Durham, North Carolina (E.D.K.); Bermaride, LLC (E.D.K.); and Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri (E.J.L.)
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Milosavljević F, Molden PE, Ingelman-Sundberg PM, Jukić APMM. Current level of evidence for improvement of antidepressant efficacy and tolerability by pharmacogenomic-guided treatment: A Systematic review and meta-analysis of randomized controlled clinical trials. Eur Neuropsychopharmacol 2024; 81:43-52. [PMID: 38340605 DOI: 10.1016/j.euroneuro.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/12/2024]
Abstract
The aim of the study was to assess the clinical utility of currently available pharmacogenomic (PGx) tools compared with treatment as usual (TAU), using a meta-analysis of dichotomous and continuous antidepressant efficacy and tolerability data from previously published clinical trials. MEDLINE, clinicaltrial.gov, EU Clinical Trials Register, WHO ICTRP and CENTRAL were systematically searched; of the 962 results originally reviewed, 15 trials were included. Antidepressant efficacy was quantified by relative and absolute changes in symptom severity after eight weeks of treatment and by response and remission rates, while tolerability was estimated by the rate of study discontinuation for any reason. In the PGx-guided patients, symptom severity reduced by an average of 31.0% after eight weeks of treatment, compared to an average reduction of 26.8% in the TAU group. Accordingly, PGx-guided patients experienced a greater reduction in symptom severity of 3.4% (95%CI: 1.6-5.3%), which corresponded to a reduction in the Hamilton Depression score of 0.75 (0.30-1.21), a 37% (15-63%) higher remission rate, and an 18% (5-33%) higher response rate compared with TAU patients, while no difference was observed in discontinuation rate between groups. Notably, the majority of associations lost statistical significance when restricting the dataset to low risk of bias studies, while certain funnel plots suggested a potential publication bias favoring the reporting of statistically significant results. In summary, PGx tools marginally enhance antidepressant efficacy, but not antidepressant tolerability; thus, additional research and advancement of PGx tools are needed to improve integration of PGx in clinical pharmacotherapy of depression.
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Affiliation(s)
- Filip Milosavljević
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Prof Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | | | - Assoc Prof Marin M Jukić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia; Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Ramadan A, Jarab AS, Al Meslamani AZ. Investigation of community pharmacists' knowledge and attitudes of pharmacogenomics testing: implication for improved pharmacogenomic testing practice. Hum Genomics 2024; 18:8. [PMID: 38291455 PMCID: PMC10825993 DOI: 10.1186/s40246-024-00574-z] [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: 10/05/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Community pharmacists must be well-equipped to advance pharmacogenomics services. Nevertheless, limited data is available regarding pharmacists' knowledge and attitudes toward pharmacogenomics testing. The present study aimed to evaluate community pharmacists' knowledge and attitudes toward pharmacogenomics testing in the UAE. METHODS In this cross-sectional study, a validated, online, self-administered survey, was randomly distributed to community pharmacists across the United Arab Emirates (UAE). RESULTS The participants demonstrated poor knowledge about pharmacogenomic testing (median score < 8). Having 10-29 (Adjusted odds ration [AOR]: 0.038; 95% CI: 0.01-0.146, p = 0.001) and 30-49 (AOR: 0.097; 95% CI: 0.04-0.237, p = 0.001) patients per day was associated with poorer knowledge. Also, receiving 10-29 (AOR: 0.046; 95% CI: 0.005-0.401, p = 0.005), 30-49 (AOR: 0.025; 95% CI: 0.003-0.211, p = 0.001), and > 50 (AOR: 0.049; 95% CI: 0.005-0.458, p = 0.008) prescriptions decreased the odds of having good knowledge. Around half (43.9%) of the participants did not show a positive attitude toward pharmacogenomic testing (median score < 11). Having 30-49 patients per day (AOR: 5.351; 95% CI: 2.414-11.860, p = 0.001) increased the odds of good knowledge while receiving 10-29 (AOR: 0.133; 95% CI: 0.056-0.315, p = 0.001) and 30-49 (AOR: 0.111; 95% CI: 0.049-0.252, p = 0.001) prescriptions a day were associated with decreased odds of positive attitude toward the pharmacogenomics testing. CONCLUSIONS The findings indicate a lack of knowledge and less-than-ideal attitudes among community pharmacists regarding pharmacogenomics testing. Enhanced efforts focused on educational initiatives and training activities related to pharmacogenomics testing is needed. Additionally, reducing workload can facilitate better knowledge acquisition and help mitigate unfavorable attitudes.
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Affiliation(s)
- Azza Ramadan
- Department of Pharmaceutical Sciences, College of Pharmacy, Al Ain University, 112612, Abu Dhabi, United Arab Emirates.
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Anan S Jarab
- Department of Pharmaceutical Sciences, College of Pharmacy, Al Ain University, 112612, Abu Dhabi, United Arab Emirates
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Ahmad Z Al Meslamani
- Department of Pharmaceutical Sciences, College of Pharmacy, Al Ain University, 112612, Abu Dhabi, United Arab Emirates
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
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11
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Leung JG. Ethnopsychopharmacology: Clinical and scientific writing pearls. Ment Health Clin 2023; 13:276-288. [PMID: 38058595 PMCID: PMC10696167 DOI: 10.9740/mhc.2023.12.276] [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: 04/03/2023] [Accepted: 09/26/2023] [Indexed: 12/08/2023] Open
Abstract
The concept of ethnopsychopharmacology aims to predict or explain the pharmacologic response to psychiatric medications based on the influence of biologic and nonbiologic factors. Interactions involving these factors are complex and influence patient outcomes in health care. Pharmacists and other clinicians working in patient care environments, research, or medical education should engage in lifelong learning to enhance ethnopsychopharmacologic knowledge gaps, which ultimately may improve and individualize care across diverse populations. Through two cases, this paper provides pearls on how biogeographical ancestry and cytochrome P450 status may influence pharmacotherapy selection, dosing, or response. A third scenario highlights a publication, like many other published works, with deficiencies in how data on ancestry, race, and ethnicity are collected or reported. Current recommendations on the use of inclusive language in scientific writing are reviewed, with attention to specific examples.
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12
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Barlati S, Minelli A, Nibbio G, Bertoni L, Necchini N, Paolini S, Muscarella A, Ubertino UB, Calzavara-Pinton I, Vita A, Gennarelli M. The role of pharmacogenetics in the treatment of major depressive disorder: a critical review. Front Psychiatry 2023; 14:1307473. [PMID: 38025425 PMCID: PMC10667493 DOI: 10.3389/fpsyt.2023.1307473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Pharmacological therapy represents one of the essential approaches to treatment of Major Depressive Disorder (MDD). However, currently available antidepressant medications show high rates of first-level treatment non-response, and several attempts are often required to find an effective molecule for a specific patient in clinical practice. In this context, pharmacogenetic analyses could represent a valuable tool to identify appropriate pharmacological treatment quickly and more effectively. However, the usefulness and the practical effectiveness of pharmacogenetic testing currently remains an object of scientific debate. The present narrative and critical review focuses on exploring the available evidence supporting the usefulness of pharmacogenetic testing for the treatment of MDD in clinical practice, highlighting both the points of strength and the limitations of the available studies and of currently used tests. Future research directions and suggestions to improve the quality of available evidence, as well as consideration on the potential use of pharmacogenetic tests in everyday clinical practice are also presented.
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Affiliation(s)
- Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessandra Minelli
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Gabriele Nibbio
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Lorenzo Bertoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Nicola Necchini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stefano Paolini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alessia Muscarella
- Department of Mental Health and Addiction Services, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Ughetta Bosco Ubertino
- Department of Mental Health and Addiction Services, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Massimo Gennarelli
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
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13
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Baldacci A, Saguin E, Balcerac A, Mouchabac S, Ferreri F, Gaillard R, Colas MD, Delacour H, Bourla A. Pharmacogenetic Guidelines for Psychotropic Drugs: Optimizing Prescriptions in Clinical Practice. Pharmaceutics 2023; 15:2540. [PMID: 38004520 PMCID: PMC10674305 DOI: 10.3390/pharmaceutics15112540] [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: 09/21/2023] [Revised: 10/15/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
The modalities for prescribing a psychotropic (dose and choice of molecule) are currently unsatisfactory, which can lead to a lack of efficacy of the treatment associated with prolonged exposure of the patient to the symptoms of his or her illness and the side effects of the molecule. In order to improve the quality of treatment prescription, a part of the current biomedical research is dedicated to the development of pharmacogenetic tools for individualized prescription. In this guideline, we will present the genes of interest with level 1 clinical recommendations according to PharmGKB for the two major families of psychotropics: antipsychotics and antidepressants. For antipsychotics, there are CYP2D6 and CYP3A4, and for antidepressants, CYP2B6, CYP2D6, and CYP2C19. The study will focus on describing the role of each gene, presenting the variants that cause functional changes, and discussing the implications for prescriptions in clinical practice.
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Affiliation(s)
- Antoine Baldacci
- Department of Psychiatry, Bégin Army Instruction Hospital, 94160 Saint-Mandé, France; (A.B.)
| | - Emeric Saguin
- Department of Psychiatry, Bégin Army Instruction Hospital, 94160 Saint-Mandé, France; (A.B.)
| | | | - Stéphane Mouchabac
- Department of Psychiatry, Saint-Antoine Hospital, Sorbonne University, 75012 Paris, France; (S.M.); (F.F.)
- ICRIN—Psychiatry (Infrastructure of Clinical Research in Neurosciences—Psychiatry), Brain Institute (ICM), Sorbonne Université, INSERM, CNRS, 75013 Paris, France
| | - Florian Ferreri
- Department of Psychiatry, Saint-Antoine Hospital, Sorbonne University, 75012 Paris, France; (S.M.); (F.F.)
- ICRIN—Psychiatry (Infrastructure of Clinical Research in Neurosciences—Psychiatry), Brain Institute (ICM), Sorbonne Université, INSERM, CNRS, 75013 Paris, France
| | - Raphael Gaillard
- Department of Psychiatry, Pôle Hospitalo-Universitaire, GHU Paris Psychiatrie & Neurosciences, 75014 Paris, France;
| | | | - Hervé Delacour
- Ecole du Val-de-Grâce, Army Health Service, 75005 Paris, France; (M.-D.C.); (H.D.)
- Biological Unit, Bégin Army Instruction Hospital, 94160 Saint-Mandé, France
| | - Alexis Bourla
- Department of Psychiatry, Saint-Antoine Hospital, Sorbonne University, 75012 Paris, France; (S.M.); (F.F.)
- ICRIN—Psychiatry (Infrastructure of Clinical Research in Neurosciences—Psychiatry), Brain Institute (ICM), Sorbonne Université, INSERM, CNRS, 75013 Paris, France
- Clariane, Medical Strategy and Innovation Department, 75008 Paris, France
- NeuroStim Psychiatry Practice, 75005 Paris, France
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14
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Forbes M, Hopwood M, Bousman CA. CYP2D6 and CYP2C19 Variant Coverage of Commercial Antidepressant Pharmacogenomic Testing Panels Available in Victoria, Australia. Genes (Basel) 2023; 14:1945. [PMID: 37895294 PMCID: PMC10606650 DOI: 10.3390/genes14101945] [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: 09/21/2023] [Revised: 10/08/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Pharmacogenomic (PGx) testing to inform antidepressant medication selection and dosing is gaining attention from healthcare professionals, patients, and payors in Australia. However, there is often uncertainty regarding which test is most suitable for a particular patient. Here, we identified and evaluated the coverage of CYP2D6 and CYP2C19 variants in commercial antidepressant PGx testing panels in Victoria, a large and ethnically diverse state of Australia. Test characteristics and star alleles tested for both genes were obtained directly from pathology laboratories offering PGx testing and compared against the Association of Molecular Pathology's recommended minimum (Tier 1) and extended (Tier 2) allele sets. Although all tests covered the minimum recommended alleles for CYP2C19, this was not the case for CYP2D6. This study emphasizes that PGx tests might not be suitable for all individuals in Australia due to the limited range of star alleles assessed. Inadequate haplotype coverage may risk misclassification of an individual's predicted metabolizer phenotype, which has ramifications for depression medication selection and dosage. This study underscores the urgent need for greater standardization in PGx testing and emphasizes the importance of considering genetic ancestry when choosing a PGx testing panel to ensure optimal clinical applicability.
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Affiliation(s)
- Malcolm Forbes
- The Institute for Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Barwon Health, Deakin University, Geelong, VIC 3220, Australia
- Department of Psychiatry, University of Melbourne, Parkville, VIC 3050, Australia; (M.H.); (C.A.B.)
| | - Mal Hopwood
- Department of Psychiatry, University of Melbourne, Parkville, VIC 3050, Australia; (M.H.); (C.A.B.)
| | - Chad A. Bousman
- Department of Psychiatry, University of Melbourne, Parkville, VIC 3050, Australia; (M.H.); (C.A.B.)
- Department of Medical Genetics, University of Calgary, Calgary, AB T2N 4N2, Canada
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15
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Roberts B, Cooper Z, Lu S, Stanley S, Majda BT, Collins KRL, Gilkes L, Rodger J, Akkari PA, Hood SD. Utility of pharmacogenetic testing to optimise antidepressant pharmacotherapy in youth: a narrative literature review. Front Pharmacol 2023; 14:1267294. [PMID: 37795032 PMCID: PMC10545970 DOI: 10.3389/fphar.2023.1267294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
Pharmacogenetics (PGx) is the study and application of how interindividual differences in our genomes can influence drug responses. By evaluating individuals' genetic variability in genes related to drug metabolism, PGx testing has the capabilities to individualise primary care and build a safer drug prescription model than the current "one-size-fits-all" approach. In particular, the use of PGx testing in psychiatry has shown promising evidence in improving drug efficacy as well as reducing toxicity and adverse drug reactions. Despite randomised controlled trials demonstrating an evidence base for its use, there are still numerous barriers impeding its implementation. This review paper will discuss the management of mental health conditions with PGx-guided treatment with a strong focus on youth mental illness. PGx testing in clinical practice, the concerns for its implementation in youth psychiatry, and some of the barriers inhibiting its integration in clinical healthcare will also be discussed. Overall, this paper provides a comprehensive review of the current state of knowledge and application for PGx in psychiatry and summarises the capabilities of genetic information to personalising medicine for the treatment of mental ill-health in youth.
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Affiliation(s)
- Bradley Roberts
- The Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- School of Biological Sciences, University of Western Australia, Crawley, WA, Australia
| | - Zahra Cooper
- The Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
| | - Stephanie Lu
- School of Psychological Science, University of Western Australia, Crawley, WA, Australia
| | - Susanne Stanley
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | | | - Khan R. L. Collins
- Western Australian Department of Health, North Metropolitan Health Service, Perth, WA, Australia
| | - Lucy Gilkes
- School of Medicine, University of Notre Dame, Fremantle, WA, Australia
- Divison of General Practice, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Jennifer Rodger
- The Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- School of Biological Sciences, University of Western Australia, Crawley, WA, Australia
| | - P. Anthony Akkari
- The Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- School of Human Sciences, University of Western Australia, Crawley, WA, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Murdoch, WA, Australia
- Division of Neurology, Duke University Medical Centre, Duke University, Durham, United States
| | - Sean D. Hood
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, WA, Australia
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16
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Gentile G, De Luca O, Del Casale A, Salerno G, Simmaco M, Borro M. Frequencies of Combined Dysfunction of Cytochromes P450 2C9, 2C19, and 2D6 in an Italian Cohort: Suggestions for a More Appropriate Medication Prescribing Process. Int J Mol Sci 2023; 24:12696. [PMID: 37628884 PMCID: PMC10454797 DOI: 10.3390/ijms241612696] [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: 07/03/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Improper drug prescription is a main cause of both drug-related harms (inefficacy and toxicity) and ineffective spending and waste of the healthcare system's resources. Nowadays, strategies to support an improved, informed prescription process may benefit from the adequate use of pharmacogenomic testing. Using next-generation sequencing, we analyzed the genomic profile for three major cytochromes P450 (CYP2C9, CYP2C19, CYP2D6) and studied the frequencies of dysfunctional isozymes (e.g., poor, intermediate, or rapid/ultra-rapid metabolizers) in a cohort of 298 Italian subjects. We found just 14.8% of subjects with a fully normal set of cytochromes, whereas 26.5% of subjects had combined cytochrome dysfunction (more than one isozyme involved). As improper drug prescription is more frequent, and more burdening, in polytreated patients, since drug-drug interactions also cause patient harm, we discuss the potential benefits of a more comprehensive PGX testing approach to support informed drug selection in such patients.
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Affiliation(s)
- Giovanna Gentile
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (G.G.); (G.S.); (M.S.)
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, Via di Grottarossa 1035/1039, 00189 Rome, Italy
| | - Ottavia De Luca
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, Via di Grottarossa 1035/1039, 00189 Rome, Italy
| | - Antonio Del Casale
- Department of Dynamic and Clinical Psychology and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189 Roma, Italy;
- Unit of Psychiatry, Sant’Andrea University Hospital, Via di Grottarossa 1035/1039, 00189 Rome, Italy
| | - Gerardo Salerno
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (G.G.); (G.S.); (M.S.)
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, Via di Grottarossa 1035/1039, 00189 Rome, Italy
| | - Maurizio Simmaco
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (G.G.); (G.S.); (M.S.)
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, Via di Grottarossa 1035/1039, 00189 Rome, Italy
| | - Marina Borro
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (G.G.); (G.S.); (M.S.)
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, Via di Grottarossa 1035/1039, 00189 Rome, Italy
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