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Chen T, O'Donnell PH, Middlestadt M, Ruhnke GW, Danahey K, van Wijk XMR, Choksi A, Knoebel R, Hartman S, Yeo KTJ, Friedman PN, Ratain MJ, Nutescu EA, O'Leary KJ, Perera MA, Meltzer DO. Implementation of pharmacogenomics into inpatient general medicine. Pharmacogenet Genomics 2023; 33:19-23. [PMID: 36729768 DOI: 10.1097/fpc.0000000000000487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pharmacogenomics is a crucial piece of personalized medicine. Preemptive pharmacogenomic testing is only used sparsely in the inpatient setting and there are few models to date for fostering the adoption of pharmacogenomic treatment in the inpatient setting. We created a multi-institutional project in Chicago to enable the translation of pharmacogenomics into inpatient practice. We are reporting our implementation process and barriers we encountered with solutions. This study, 'Implementation of Point-of-Care Pharmacogenomic Decision Support Accounting for Minority Disparities', sought to implement pharmacogenomics into inpatient practice at three sites: The University of Chicago, Northwestern Memorial Hospital, and the University of Illinois at Chicago. This study involved enrolling African American adult patients for preemptive genotyping across a panel of actionable germline variants predicting drug response or toxicity risk. We report our approach to implementation and the barriers we encountered engaging hospitalists and general medical providers in the inpatient pharmacogenomic intervention. Our strategies included: a streamlined delivery system for pharmacogenomic information, attendance at hospital medicine section meetings, use of physician and pharmacist champions, focus on hospitalists' care and optimizing system function to fit their workflow, hand-offs, and dealing with hospitalists turnover. Our work provides insights into strategies for the initial engagement of inpatient general medicine providers that we hope will benefit other institutions seeking to implement pharmacogenomics in the inpatient setting.
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Affiliation(s)
- Thomas Chen
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | - Gregory W Ruhnke
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | | | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | - Randall Knoebel
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | - Seth Hartman
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | | | - Paula N Friedman
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA
| | - Mark J Ratain
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kevin J O'Leary
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA
| | - David O Meltzer
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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Saulsberry L, Danahey K, Middlestadt M, O’Leary KJ, Nutescu EA, Chen T, Lee JC, Ruhnke GW, George D, House L, van Wijk XMR, Yeo KTJ, Choksi A, Hartman SW, Knoebel RW, Friedman PN, Rasmussen LV, Ratain MJ, Perera MA, Meltzer DO, O’Donnell PH. Applicability of Pharmacogenomically Guided Medication Treatment during Hospitalization of At-Risk Minority Patients. J Pers Med 2021; 11:1343. [PMID: 34945816 PMCID: PMC8709436 DOI: 10.3390/jpm11121343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/17/2022] Open
Abstract
Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19-86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.
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Affiliation(s)
- Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, IL 60637, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Center for Research Informatics, The University of Chicago, Chicago, IL 60637, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
| | - Kevin J. O’Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, IL 60612, USA;
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Thomas Chen
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL 60612, USA;
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - David George
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
| | - Larry House
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
| | - Xander M. R. van Wijk
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Kiang-Teck J. Yeo
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Seth W. Hartman
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Randall W. Knoebel
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Paula N. Friedman
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - Luke V. Rasmussen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Mark J. Ratain
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Minoli A. Perera
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - David O. Meltzer
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - Peter H. O’Donnell
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
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Reizine N, Danahey K, Schierer E, Liu P, Middlestadt M, Ludwig J, Truong TM, van Wijk XMR, Yeo KTJ, Malec M, Ratain MJ, O'Donnell PH. Impact of CYP2D6 Pharmacogenomic Status on Pain Control Among Opioid-Treated Oncology Patients. Oncologist 2021; 26:e2042-e2052. [PMID: 34423496 DOI: 10.1002/onco.13953] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Several opioids have pharmacogenomic associations impacting analgesic efficacy. However, germline pharmacogenomic testing is not routinely incorporated into supportive oncology. We hypothesized that CYP2D6 profiling would correlate with opioid prescribing and hospitalizations. MATERIALS AND METHODS We analyzed 61,572 adult oncology patients from 2012 to 2018 for opioid exposures. CYP2D6 metabolizer phenotype (ultra-rapid [UM], normal metabolizer [NM], intermediate [IM], or poor [PM]), the latter two of which may cause inefficacy of codeine, tramadol, and standard-dose hydrocodone, was determined for patients genotyped for reasons unrelated to pain. The primary endpoint was number of opioid medications received during longitudinal care (IM/PMs vs. NMs). Secondary endpoint was likelihood of pain-related hospital encounters. RESULTS Most patients with cancer (n = 34,675, 56%) received multiple opioids (average 2.8 ± 1.6/patient). Hydrocodone was most commonly prescribed (62%), followed by tramadol, oxycodone, and codeine. In the CYP2D6 genotyped cohort (n = 105), IM/PMs received a similar number of opioids (3.4 ± 1.4) as NMs (3.3 ± 1.9). However, IM/PMs were significantly more likely to experience pain-related hospital encounters compared with NMs, independent of other variables (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-23.6; p = .03). IM/PMs were also more likely to be treated with later-line opioids that do not require CYP2D6 metabolism, such as morphine and hydromorphone (OR = 3.3; 95% CI, 1.1-9.8; p = .03). CONCLUSION CYP2D6 genotype may identify patients with cancer at increased risk for inadequate analgesia when treated with typical first-line opioids like codeine, tramadol, or standard-dose hydrocodone. Palliative care considerations are an integral part of optimal oncology care, and these findings justify prospective evaluation of preemptive genotyping as a strategy to improve oncology pain management. IMPLICATIONS FOR PRACTICE Genomic variation in metabolic enzymes can predispose individuals to inefficacy when receiving opioid pain medications. Patients with intermediate and/or poor CYP2D6 metabolizer status do not adequately convert codeine, tramadol, and hydrocodone into active compounds, with resulting increased risk of inadequate analgesia. This study showed that patients with cancer frequently receive CYP2D6-dependent opioids. However, patients with CYP2D6 intermediate and poor metabolizer status had increased numbers of pain-related hospitalizations and more frequently required the potent non-CYP2D6 opioids morphine and hydromorphone. This may reflect inadequate initial analgesia with the common "first-line" CYP2D6-metabolized opioids. Preemptive genotyping to guide opioid prescribing during cancer care may improve pain-related patient outcomes.
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Affiliation(s)
- Natalie Reizine
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA.,Center for Research Informatics, University of Chicago, Chicago, Illinois, USA
| | - Emily Schierer
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Ping Liu
- Department of Public Health Services, University of Chicago, Chicago, Illinois, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Jenna Ludwig
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Tien M Truong
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Xander M R van Wijk
- Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Kiang-Teck J Yeo
- Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Monica Malec
- Section of Geriatric and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Mark J Ratain
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
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