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Cernat A, Samaan Z, Abelson J, Ramdyal A, Shaikh H, Vanstone M. Patient perspectives on pharmacogenomic (PGx) testing for antidepressant prescribing in primary care: a qualitative description study. J Community Genet 2024; 15:293-309. [PMID: 38587601 PMCID: PMC11217204 DOI: 10.1007/s12687-024-00705-y] [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: 01/20/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024] Open
Abstract
Many patients with major depressive disorder (MDD) try multiple antidepressants before finding one that works well and is tolerable. Pharmacogenomic (PGx) testing was developed to facilitate more efficacious prescribing. This technology has not been robustly implemented clinically. Patient perspectives are critical to policy decisions, but the views of patients with MDD about the use of PGx testing to guide antidepressant prescribing have not been extensively examined, particularly in publicly funded healthcare systems. The purpose of this qualitative description study was to produce actionable patient perspectives evidence to inform future technology assessment of PGx testing. We conducted semi-structured interviews with 21 adults with MDD for which antidepressants were indicated in Ontario, Canada, and used the Ontario Decision Determinants Framework to conduct an unconstrained deductive content analysis. Patients expressed views about the overall clinical benefit of PGx testing in depression care, preferences for deployment of testing, perspectives on ethical considerations, opinions about equity and patient care, and beliefs regarding the feasibility of adopting PGx testing into the healthcare system. They also worried about the possibility of conflicts of interest between PGx test manufacturers and pharmaceutical companies. This study provides policymakers with patient priorities to facilitate the development of patient-centred policies. It highlights that formal adoption of PGx testing into the healthcare system requires a focus on equity of access and health outcomes.
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Affiliation(s)
- Alexandra Cernat
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada
- Health Policy PhD Program, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, L8S 4L8, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, L8S 4L8, Canada
| | - Julia Abelson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, L8S 4L8, Canada
| | - Amanada Ramdyal
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada
| | - Hadia Shaikh
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada
- Biomedical Discovery and Commercialization Program, Faculty of Health Sciences, McMaster University, Hamilton, L8S 4L8, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada.
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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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Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010118. [PMID: 36676742 PMCID: PMC9863497 DOI: 10.3390/medicina59010118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
Pharmacotherapy for major depressive disorder (MDD) typically consists of trial-and-error and clinician preference approaches, where patients often fail one or more antidepressants before finding an optimal regimen. Pharmacogenomics (PGx) can assist in prescribing appropriate antidepressants, thereby reducing the time to MDD remission and occurrence of adverse drug events. Since many antidepressants are metabolized by and/or inhibit cytochrome P450 enzymes (e.g., CYP2C19 or CYP2D6), drug-induced phenoconversion is common in patients on antidepressant combinations. This condition influences the interpretation of a patient's PGx results, overall risk of ineffective/adverse medication response due to multi-drug interactions, and the recommendations. This complex case describes a patient with MDD, generalized anxiety disorder, and chronic pain who experienced a fall due to excessive sedation following a prescribing cascade of fluoxetine, bupropion, and doxepin. These antidepressants delivered a significant additive sedative effect and interacted with the patient's hydrocodone, potentially contributing to uncontrolled pain, upward dose titration of hydrocodone, and a higher overall sedative burden. The PGx results and drug-induced phenoconversion described in this case report explain the patient's excessive sedation and possibly ineffective/toxic antidepressant and opioid treatment. This case report also illustrates how a more timely multi-drug interaction assessment (preferably in conjunction with preemptive PGx testing) may have informed a different prescribing pattern, reduced/avoided a prescribing cascade, and potentially prevented a drug-related fall.
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Isono T, Hira D, Ikeda Y, Kawahara M, Noda S, Nishida A, Inatomi O, Fujimoto N, Andoh A, Terada T, Morita SY. Single-Nucleotide Polymorphisms, c.415C > T (Arg139Cys) and c.416G > A (Arg139His), in the NUDT15 Gene Are Associated with Thiopurine-Induced Leukopenia. Biol Pharm Bull 2023; 46:412-418. [PMID: 36858569 DOI: 10.1248/bpb.b22-00686] [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: 03/03/2023]
Abstract
While nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) gene polymorphism Arg139Cys (rs116855232) is known to be a risk factor for thiopurine-induced severe leukopenia, association with the NUDT15 gene polymorphism Arg139His (rs147390019) has not yet been clarified. In addition, the accuracy of TaqMan PCR to assess these two polymorphisms has not been investigated. In this study, we evaluated TaqMan PCR for detection of the NUDT15 single-nucleotide polymorphisms (SNPs) and examined the clinical impact of Arg139His on thiopurine-induced leukopenia. First, we demonstrated that a TaqMan PCR assay successfully detected the Arg139His polymorphism of NUDT15 in clinical samples. Next, the NUDT15 gene polymorphisms (Arg139Cys and Arg139His) were separately analyzed by TaqMan Real-Time PCR in 189 patients from August 2018 to July 2019. The incidences of leukopenia within 2 years were 16.2, 57.9, and 100% for arginine (Arg)/Arg, Arg/cysteine (Cys), and Arg/histidine (His), respectively. The leukopenia was significantly increased in Arg/Cys and Arg/His compared with Arg/Arg. This retrospective clinical study indicated that, in addition to Arg139Cys, Arg139His may be clinically associated with a high risk of leukopenia. Pharmacogenomics will help in selecting drugs and determining the individualized dosage of thiopurine drugs.
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Affiliation(s)
- Tetsuichiro Isono
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital.,Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital.,College of Pharmaceutical Sciences, Ritsumeikan University
| | - Yoshito Ikeda
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Masahiro Kawahara
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Satoshi Noda
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Atsushi Nishida
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Osamu Inatomi
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Noriki Fujimoto
- Department of Dermatology, Shiga University of Medical Science
| | - Akira Andoh
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital.,Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital
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Real-World Impact of a Pharmacogenomics-Enriched Comprehensive Medication Management Program. J Pers Med 2022; 12:jpm12030421. [PMID: 35330421 PMCID: PMC8949247 DOI: 10.3390/jpm12030421] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/23/2022] [Accepted: 03/07/2022] [Indexed: 02/04/2023] Open
Abstract
The availability of clinical decision support systems (CDSS) and other methods for personalizing medicine now allows evaluation of their real-world impact on healthcare delivery. For example, addressing issues associated with polypharmacy in older patients using pharmacogenomics (PGx) and comprehensive medication management (CMM) is thought to hold great promise for meaningful improvements across the goals of the Quadruple Aim. However, few studies testing these tools at scale, using relevant system-wide metrics, and under real-world conditions, have been published to date. Here, we document a reduction of ~$7000 per patient in direct medical charges (a total of $37 million over 5288 enrollees compared to 22,357 non-enrolled) in Medicare Advantage patients (≥65 years) receiving benefits through a state retirement system over the first 32 months of a voluntary PGx-enriched CMM program. We also observe a positive shift in healthcare resource utilization (HRU) away from acute care services and toward more sustainable and cost-effective primary care options. Together with improvements in medication risk assessment, patient/provider communication via pharmacist-mediated medication action plans (MAP), and the sustained positive trends in HRU, we suggest these results validate the use of a CDSS to unify PGx and CMM to optimize care for this and similar patient populations.
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