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Gaedigk A, Turner AJ, Haidar CE, Empey PE, Offer SM. Response to "DPYD genotyping panels: Impact of population diversity". Clin Transl Sci 2024; 17:e13806. [PMID: 38637962 PMCID: PMC11026573 DOI: 10.1111/cts.13806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 03/15/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024] Open
Affiliation(s)
- Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic InnovationChildren's Mercy Research Institute (CMRI)Kansas CityMissouriUSA
| | | | - Cyrine E. Haidar
- Department of Pharmacy and Pharmaceutical SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Philip E. Empey
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPennsylvaniaUSA
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2
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Murugan M, Yuan B, Venner E, Ballantyne CM, Robinson KM, Coons JC, Wang L, Empey PE, Gibbs RA. Empowering personalized pharmacogenomics with generative AI solutions. J Am Med Inform Assoc 2024:ocae039. [PMID: 38447590 DOI: 10.1093/jamia/ocae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/06/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVE This study evaluates an AI assistant developed using OpenAI's GPT-4 for interpreting pharmacogenomic (PGx) testing results, aiming to improve decision-making and knowledge sharing in clinical genetics and to enhance patient care with equitable access. MATERIALS AND METHODS The AI assistant employs retrieval-augmented generation (RAG), which combines retrieval and generative techniques, by harnessing a knowledge base (KB) that comprises data from the Clinical Pharmacogenetics Implementation Consortium (CPIC). It uses context-aware GPT-4 to generate tailored responses to user queries from this KB, further refined through prompt engineering and guardrails. RESULTS Evaluated against a specialized PGx question catalog, the AI assistant showed high efficacy in addressing user queries. Compared with OpenAI's ChatGPT 3.5, it demonstrated better performance, especially in provider-specific queries requiring specialized data and citations. Key areas for improvement include enhancing accuracy, relevancy, and representative language in responses. DISCUSSION The integration of context-aware GPT-4 with RAG significantly enhanced the AI assistant's utility. RAG's ability to incorporate domain-specific CPIC data, including recent literature, proved beneficial. Challenges persist, such as the need for specialized genetic/PGx models to improve accuracy and relevancy and addressing ethical, regulatory, and safety concerns. CONCLUSION This study underscores generative AI's potential for transforming healthcare provider support and patient accessibility to complex pharmacogenomic information. While careful implementation of large language models like GPT-4 is necessary, it is clear that they can substantially improve understanding of pharmacogenomic data. With further development, these tools could augment healthcare expertise, provider productivity, and the delivery of equitable, patient-centered healthcare services.
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Affiliation(s)
- Mullai Murugan
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, United States
| | - Bo Yuan
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, United States
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Eric Venner
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, United States
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Christie M Ballantyne
- Sections of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | | | - James C Coons
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Pharmacy, UPMC Presbyterian-Shadyside Hospital, Pittsburgh, PA, United States
| | - Liwen Wang
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, United States
| | - Philip E Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
- Institute for Precision Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, United States
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
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3
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Venner E, Patterson K, Kalra D, Wheeler MM, Chen YJ, Kalla SE, Yuan B, Karnes JH, Walker K, Smith JD, McGee S, Radhakrishnan A, Haddad A, Empey PE, Wang Q, Lichtenstein L, Toledo D, Jarvik G, Musick A, Gibbs RA. The frequency of pathogenic variation in the All of Us cohort reveals ancestry-driven disparities. Commun Biol 2024; 7:174. [PMID: 38374434 PMCID: PMC10876563 DOI: 10.1038/s42003-023-05708-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/13/2023] [Indexed: 02/21/2024] Open
Abstract
Disparities in data underlying clinical genomic interpretation is an acknowledged problem, but there is a paucity of data demonstrating it. The All of Us Research Program is collecting data including whole-genome sequences, health records, and surveys for at least a million participants with diverse ancestry and access to healthcare, representing one of the largest biomedical research repositories of its kind. Here, we examine pathogenic and likely pathogenic variants that were identified in the All of Us cohort. The European ancestry subgroup showed the highest overall rate of pathogenic variation, with 2.26% of participants having a pathogenic variant. Other ancestry groups had lower rates of pathogenic variation, including 1.62% for the African ancestry group and 1.32% in the Latino/Admixed American ancestry group. Pathogenic variants were most frequently observed in genes related to Breast/Ovarian Cancer or Hypercholesterolemia. Variant frequencies in many genes were consistent with the data from the public gnomAD database, with some notable exceptions resolved using gnomAD subsets. Differences in pathogenic variant frequency observed between ancestral groups generally indicate biases of ascertainment of knowledge about those variants, but some deviations may be indicative of differences in disease prevalence. This work will allow targeted precision medicine efforts at revealed disparities.
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Affiliation(s)
- Eric Venner
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA.
| | - Karynne Patterson
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Divya Kalra
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Marsha M Wheeler
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Yi-Ju Chen
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Sara E Kalla
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Bo Yuan
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Jason H Karnes
- University of Arizona, R Ken Coit College of Pharmacy, Department of Pharmacy Practice and Science, Tucson, AZ, USA
- Vanderbilt University Medical Center, Department of Biomedical Informatics, Boston, MA, USA
| | - Kimberly Walker
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Joshua D Smith
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Sean McGee
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | | | - Andrew Haddad
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Qiaoyan Wang
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Diana Toledo
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Gail Jarvik
- Department of Medicine (Medical Genetics), University of Washington School of Medicine, Seattle, WA, USA
- Department of Genome Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Anjene Musick
- NIH All of Us Research Program, National Institutes of Health Office of the Director, Bethesda, MD, USA
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
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4
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Turner AJ, Haidar CE, Yang W, Boone EC, Offer SM, Empey PE, Haddad A, Tahir S, Scharer G, Broeckel U, Gaedigk A. Updated DPYD HapB3 haplotype structure and implications for pharmacogenomic testing. Clin Transl Sci 2024; 17:e13699. [PMID: 38129972 PMCID: PMC10777430 DOI: 10.1111/cts.13699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 09/25/2023] [Revised: 11/22/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
The DPYD gene encodes dihydropyrimidine dehydrogenase, the rate-limiting enzyme for the metabolism of fluoropyrimidines 5-fluorouracil and capecitabine. Genetic variants in DPYD have been associated with altered enzyme activity, therefore accurate detection and interpretation is critical to predict metabolizer status for individualized fluoropyrimidine therapy. The most commonly observed deleterious variation is the causal variant linked to the previously described HapB3 haplotype, c.1129-5923C>G (rs75017182) in intron 10, which introduces a cryptic splice site. A benign synonymous variant in exon 11, c.1236G>A (rs56038477) is also linked to HapB3 and is commonly used for testing. Previously, these single-nucleotide polymorphisms (SNPs) have been reported to be in perfect linkage disequilibrium (LD); therefore, c.1236G>A is often utilized as a proxy for the function-altering intronic variant. Clinical genotyping of DPYD identified a patient who had c.1236G>A, but not c.1129-5923C>G, suggesting that these two SNPs may not be in perfect LD, as previously assumed. Additional individuals with c.1236G>A, but not c.1129-5923C>G, were identified in the Children's Mercy Data Warehouse and the All of Us Research Program version 7 cohort substantiating incomplete SNP linkage. Consequently, testing only c.1236G>A can generate false-positive results in some cases and lead to suboptimal dosing that may negatively impact patient therapy and prospect of survival. Our data show that DPYD genotyping should include the functional variant c.1129-5923C>G, and not the c.1236G>A proxy, to accurately predict DPD activity.
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Affiliation(s)
| | - Cyrine E. Haidar
- Department of Pharmacy and Pharmaceutical SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Wenjian Yang
- Department of Pharmacy and Pharmaceutical SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Erin C. Boone
- Division of Clinical Pharmacology, Toxicology & Therapeutic InnovationChildren's Mercy Research Institute (CMRI)Kansas CityMissouriUSA
| | - Steven M. Offer
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | - Philip E. Empey
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPennsylvaniaUSA
| | - Andrew Haddad
- Department of Pharmaceutical SciencesUniversity of Pittsburgh School of PharmacyPittsburghPennsylvaniaUSA
| | - Saba Tahir
- Medical College of Wisconsin, School of PharmacyMilwaukeeWisconsinUSA
| | | | | | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic InnovationChildren's Mercy Research Institute (CMRI)Kansas CityMissouriUSA
- School of MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
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5
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Abstract
N-Acetylcysteine (NAC) has shown promise as a putative neurotherapeutic for traumatic brain injury (TBI). Yet, many such promising compounds have limited ability to cross the blood-brain barrier (BBB), achieve therapeutic concentrations in brain, demonstrate target engagement, among other things, that have hampered successful translation. A pharmacologic strategy for overcoming poor BBB permeability and/or efflux out of the brain of organic acid-based, small molecule therapeutics such as NAC is co-administration with a targeted or nonselective membrane transporter inhibitor. Probenecid is a classic ATP-binding cassette and solute carrier inhibitor that blocks transport of organic acids, including NAC. Accordingly, combination therapy using probenecid as an adjuvant with NAC represents a logical neurotherapeutic strategy for treatment of TBI (and other CNS diseases). We have completed a proof-of-concept pilot study using this drug combination in children with severe TBI-the Pro-NAC Trial (ClinicalTrials.gov NCT01322009). In this review, we will discuss the background and rationale for combination therapy with probenecid and NAC in TBI, providing justification for further clinical investigation.
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Affiliation(s)
- Robert S B Clark
- Departments of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA.
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Philip E Empey
- Department of Pharmacy & Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Departments of Critical Care Medicine, Anesthesiology, and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
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6
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Coons JC, Empey PE. Pharmacogenomics in the Management of Pulmonary Arterial Hypertension: Current Perspectives. Pharmgenomics Pers Med 2023; 16:729-737. [PMID: 37457231 PMCID: PMC10349598 DOI: 10.2147/pgpm.s361222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease with heterogeneous causes that can lead to right ventricular (RV) failure and death if left untreated. There are currently 10 medications representative of five unique pharmacologic classes that are approved for treatment. These have led to significant improvements in overall clinical outcome. However, substantial variability in dosing requirements and treatment response is evident, leading to suboptimal outcome for many patients. Furthermore, dosing is empiric and iterative and can lead to delays in meeting treatment goals and burdensome adverse effects. Pharmacogenomic (PGx) associations have been reported with certain PAH medications, such as treprostinil and bosentan, and can explain some of the variability in response. Relevant genes associated with treprostinil include CYP2C8, CYP2C9, CAMK2D, and PFAS. CYP2C8 and CYP2C9 are the genes encoding the major metabolizing liver enzymes for treprostinil, and reduced function variants (*2, *3) with CYP2C9 were associated with lower treatment persistence. Additionally, a higher CYP2C9 activity score was associated with a significantly less risk of treatment discontinuation. Other genes of interest that have been explored with treprostinil include CAMK2D, which is associated with right ventricular dysfunction and significantly higher dose requirements. Similarly, PFAS is associated with lower concentrations of cyclic adenosine monophosphate and significantly higher dose requirements. Genes of interest with the endothelin receptor antagonist (ERA) class include GNG2 and CYP2C9. A genetic variant in GNG2 (rs11157866) was linked to a significantly increased rate of clinical improvement with ERAs. The *2 variant with CYP2C9 (encoding for the major metabolizing enzyme for bosentan) was significantly associated with a higher risk for elevations in hepatic aminotransferases and liver injury. In summary, this article reviews the relevant pharmacogenes that have been associated to date with dosing and outcome among patients who received PAH medications.
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Affiliation(s)
- James C Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- Department of Pharmacy, UPMC Presbyterian-Shadyside Hospital, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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7
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Ramsey LB, Gong L, Lee SB, Wagner JB, Zhou X, Sangkuhl K, Adams SM, Straka RJ, Empey PE, Boone EC, Klein TE, Niemi M, Gaedigk A. PharmVar GeneFocus: SLCO1B1. Clin Pharmacol Ther 2023; 113:782-793. [PMID: 35797228 PMCID: PMC10900141 DOI: 10.1002/cpt.2705] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [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] [Received: 04/01/2022] [Accepted: 06/24/2022] [Indexed: 11/06/2022]
Abstract
The Pharmacogene Variation Consortium (PharmVar) is now providing star (*) allele nomenclature for the highly polymorphic human SLCO1B1 gene encoding the organic anion transporting polypeptide 1B1 (OATP1B1) drug transporter. Genetic variation within the SLCO1B1 gene locus impacts drug transport, which can lead to altered pharmacokinetic profiles of several commonly prescribed drugs. Variable OATP1B1 function is of particular importance regarding hepatic uptake of statins and the risk of statin-associated musculoskeletal symptoms. To introduce this important drug transporter gene into the PharmVar database and serve as a unified reference of haplotype variation moving forward, an international group of gene experts has performed an extensive review of all published SLCO1B1 star alleles. Previously published star alleles were self-assigned by authors and only loosely followed the star nomenclature system that was first developed for cytochrome P450 genes. This nomenclature system has been standardized by PharmVar and is now applied to other important pharmacogenes such as SLCO1B1. In addition, data from the 1000 Genomes Project and investigator-submitted data were utilized to confirm existing haplotypes, fill knowledge gaps, and/or define novel star alleles. The PharmVar-developed SLCO1B1 nomenclature has been incorporated by the Clinical Pharmacogenetics Implementation Consortium (CPIC) 2022 guideline on statin-associated musculoskeletal symptoms.
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Affiliation(s)
- Laura B Ramsey
- Divisions of Clinical Pharmacology and Research in Patient Services, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Seung-Been Lee
- Precision Medicine Institute, Macrogen Inc., Seoul, Korea
| | - Jonathan B Wagner
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Xujia Zhou
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Solomon M Adams
- School of Pharmacy, Shenandoah University, Fairfax, Virginia, USA
| | - Robert J Straka
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philip E Empey
- School of Pharmacy and Institute for Precision Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erin C Boone
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
- Department of Medicine (BMIR), Stanford University, Stanford, California, USA
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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8
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Cavallari LH, Limdi NA, Beitelshees AL, Lee JC, Duarte JD, Franchi F, Tuteja S, Giri J, Empey PE, Kreutz RP, Skaar TC, Allen JM, Coons JC, Gong Y, McDonough CW, Stevenson JM, Thomas CD, Johnson JA, Stouffer GA, Angiolillo DJ, Lee CR. Evaluation of Potential Racial Disparities in CYP2C19-Guided P2Y 12 Inhibitor Prescribing After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2023; 113:615-623. [PMID: 36306392 PMCID: PMC9957848 DOI: 10.1002/cpt.2776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/21/2022] [Indexed: 01/16/2023]
Abstract
Black patients suffer worse outcomes after percutaneous coronary intervention (PCI) than White patients. Inequities in antiplatelet prescribing may contribute to this health disparity. We compared P2Y12 inhibitor prescribing by race following CYP2C19 genotyping to guide antiplatelet therapy selection after PCI. Patients from 9 sites that performed clinical CYP2C19 genotyping after PCI were included. Alternative therapy (e.g., prasugrel or ticagrelor) was recommended for CYP2C19 no-function allele carriers, in whom clopidogrel is predicted to be less effective. The primary outcome was choice of P2Y12 inhibitor (clopidogrel vs. alternative therapy) based on genotype. Of 3,342 patients included, 2,448 (73%) were White, and 659 (20%) were Black. More Black than White patients had a no-function allele (34.3% vs. 29.7%, P = 0.024). At hospital discharge following PCI, 44.2% of Black and 44.0% of White no-function allele carriers were prescribed alternative therapy. At the time of the last follow-up within 12 months, numerically fewer Black (51.8%) than White (56.7%) no-function allele carriers were prescribed alternative therapy (P = 0.190). However, the difference was not significant after accounting for other factors associated with P2Y12 inhibitor selection (odds ratio 0.79, 95% confidence interval 0.58-1.08). Alternative therapy use did not differ between Black (14.3%) and White (16.7%) patients without a no-function allele (P = 0.232). Among real-world patients who received CYP2C19 testing after PCI, P2Y12 inhibitor prescribing rates did not differ between Black and White patients. Our data suggest an absence of racial disparity in genotype-guided antiplatelet prescribing among patients receiving CYP2C19 testing.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Nita A. Limdi
- Department of Neurology, Program for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, AL
| | - Amber L. Beitelshees
- University of Maryland School of Medicine, Department of Medicine and Program for Personalized and Genomic Medicine, Baltimore, MD
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | | | - Todd C. Skaar
- Indiana University School of Medicine, Indianapolis, IN
| | - John M. Allen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando, FL
| | - James C. Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
| | | | - Craig R. Lee
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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9
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Haga SB, Chung WK, Cubano LA, Curry TB, Empey PE, Ginsburg GS, Mangold K, Miyake CY, Prakash SK, Ramsey LB, Rowley R, Rohrer Vitek CR, Skaar TC, Wynn J, Manolio TA. Development of Competency-based Online Genomic Medicine Training (COGENT). Per Med 2023; 20:55-64. [PMID: 36416152 PMCID: PMC10291206 DOI: 10.2217/pme-2022-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/17/2022] [Indexed: 11/25/2022]
Abstract
The fields of genetics and genomics have greatly expanded across medicine through the development of new technologies that have revealed genetic contributions to a wide array of traits and diseases. Thus, the development of widely available educational resources for all healthcare providers is essential to ensure the timely and appropriate utilization of genetics and genomics patient care. In 2020, the National Human Genome Research Institute released a call for new proposals to develop accessible, sustainable online education for health providers. This paper describes the efforts of the six teams awarded to reach the goal of providing genetic and genomic training modules that are broadly available for busy clinicians.
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Affiliation(s)
- Susanne B Haga
- Department of Medicine, Duke University School of Medicine, Program in Precision Medicine, 101 Science Drive, Durham, NC 27708, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620 New York, NY 10032, USA
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Luis A Cubano
- National Human Genome Research Institute, Division of Genomic Medicine, 6700B Rockledge Dr, Suite 3100, Bethesda, MD 20892-6908, USA
| | - Timothy B Curry
- Center for Individualized Medicine, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Anesthesia & Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Philip E Empey
- Department of Pharmacy & Therapeutics, Pharmacogenomics Center of Excellence, University of Pittsburgh School of Pharmacy, 9064 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Geoffrey S Ginsburg
- National Institutes of Health, All of Us Research Program, Bethesda, MD 20892, USA
| | - Kara Mangold
- Center for Individualized Medicine, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Christina Y Miyake
- Department of Pediatrics, Texas Children’s Hospital, 6651 Main Street, Suite E1960.22, Houston, TX 77030, USA
- Department of Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Siddharth K Prakash
- Department of Internal Medicine, Division of Medical Genetics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Laura B Ramsey
- Divisions of Clinical Pharmacology & Research in Patient Services, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Robb Rowley
- National Human Genome Research Institute, Division of Genomic Medicine, 6700B Rockledge Dr, Suite 3100, Bethesda, MD 20892-6908, USA
| | - Carolyn R Rohrer Vitek
- Center for Individualized Medicine, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620 New York, NY 10032, USA
| | - Teri A Manolio
- National Human Genome Research Institute, Division of Genomic Medicine, 6700B Rockledge Dr, Suite 3100, Bethesda, MD 20892-6908, USA
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10
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Zheng R, Valicherla GR, Zhang J, Nuttall J, Silvera P, Marshall LJ, Empey PE, Rohan LC. Transport and Permeation Properties of Dapivirine: Understanding Potential Drug-Drug Interactions. Pharmaceutics 2022; 14:1948. [PMID: 36145696 PMCID: PMC9501983 DOI: 10.3390/pharmaceutics14091948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/03/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
The dapivirine (DPV) vaginal ring was developed by the nonprofit International Partnership for Microbicides (IPM) for reducing the risk of HIV infection. A clinical study (IPM 028) showed that concomitant use of the DPV ring and miconazole (MIC) altered DPV pharmacokinetic profile. In this work, we investigated whether or not DPV transport and permeation contributed to the observed DPV-MIC interaction. Our study evaluated the interaction between DPV and several transporters that are highly expressed in the human female reproductive tract, including MRP1, MRP4, P-gp, BCRP, and ENT1, using vesicular and cellular systems. We also evaluated the impact of DPV/MIC on cellular tight junctions by monitoring transepithelial electrical resistance with the Ussing chamber. Lastly, we evaluated the effect of MIC on DPV permeability across human cervical tissue. Our findings showed that DPV was not a substrate of MRP1, MRP4, P-gp, BCRP, or ENT1 transporters. Additionally, DPV did not inhibit the activity of these transporters. DPV, MIC, and their combination also did not disrupt cellular tight junctions. MIC did not affect DPV tissue permeability but significantly reduced DPV tissue levels. Therefore, our results suggest that the DPV-MIC interaction is not due to these five transporters, altered tight junction integrity, or altered tissue permeability.
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Affiliation(s)
- Ruohui Zheng
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Magee-Womens Research Institute, Pittsburgh, PA 15213, USA
| | - Guru R. Valicherla
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Magee-Womens Research Institute, Pittsburgh, PA 15213, USA
| | - Junmei Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Magee-Womens Research Institute, Pittsburgh, PA 15213, USA
| | - Jeremy Nuttall
- International Partnership for Microbicides, Silver Spring, MD 20910, USA
| | - Peter Silvera
- Advanced Bioscience Laboratories, Rockville, MD 20850, USA
| | - Leslie J. Marshall
- Preclinical Microbicide and Prevention Research Branch, Prevention Sciences Program, Division of AIDS, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892, USA
| | - Philip E. Empey
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Lisa C. Rohan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Magee-Womens Research Institute, Pittsburgh, PA 15213, USA
- Department of Obstetrics, Gynecology, Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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11
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Birabaharan J, West RE, Nolin TD, Traube C, Bell MJ, Empey PE. Simultaneous detection of a panel of nine sedatives and metabolites in plasma from critically ill pediatric patients via UPLC-MS/MS. J Pharm Biomed Anal 2022; 218:114853. [PMID: 35659658 PMCID: PMC9302904 DOI: 10.1016/j.jpba.2022.114853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/20/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
Sedative use can result in adverse drug reactions. Intensive care unit patients are especially at risk and pharmacokinetic modeling of drug concentrations is an approach to develop precision dosing strategies. However, limited blood sampling availability in critically ill children and need for multiple assays to quantify a variety of commonly used sedatives creates logistical challenges. The goal of this project was to develop a sensitive and selective assay for the simultaneous quantification of a panel of sedatives comprised of midazolam (MDZ), alpha hydroxymidazolam (1- OH MDZ), dexmedetomidine (DEX), morphine (MOR), morphine-3-glucuronide (M3G), morphine-6-glucuronide (M6G), fentanyl (FEN), norfentanyl (NF), and hydromorphone (HM) in small volume pediatric plasma samples. A sensitive and efficient ultra-high performance liquid chromatography-mass spectrometry (UPLC-MS/MS) method was developed following FDA guidance for bioanalytical validation. Minimal sample preparation consisting of simple protein precipitation extraction using acetonitrile with internal standards was utilized. Analyte separation was achieved using a gradient mixture of (A: 0.15% formic acid in water and B: Acetonitrile) and a Waters Acquity C18, 1.7 µm (2.1 × 100 mm) column. Assays were linear over the clinical concentration ranges: MDZ, MOR, HM: 0.5-125 ng/mL; 1-OH MDZ, M3G, M6G: 5-500 ng/mL; and DEX, FEN, NF: 0.05-7.5 ng/mL (R2 > 0.99 for all). Assay run time was 10 min and required only 100 μL of plasma. Initial testing of samples from pediatric patients demonstrates adequacy of assay to measure sedatives and metabolites at clinical concentrations confidently in low volumes of plasma. This novel highly-sensitive and specific method to measure a total of nine different analytes (five sedatives, four metabolites) simultaneously enables comprehensive analysis of a panel of sedatives in small volumes such as in pediatric ICU patients.
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Affiliation(s)
- Jonathan Birabaharan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raymond E West
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chani Traube
- Division of Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Children's National Hospital, Washington DC, USA
| | - Philip E Empey
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
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12
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Raymond M, Critchlow E, Rice SM, Wodoslawsky S, Berger SI, Hegde M, Empey PE, Al-Kouatly HB. Fetal pharmacogenomics: A promising addition to complex neonatal care. Mol Genet Metab 2022; 137:140-145. [PMID: 36029725 DOI: 10.1016/j.ymgme.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/06/2022] [Accepted: 08/07/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Pharmacogenomics (PGx) characterizes genetic variation in medication response. 85-95% of the population carries actionable PGx variants. No prior studies have demonstrated the application and feasibility of PGx in prenatal testing. We assessed parental desire for PGx findings from fetal exome sequencing (ES), evaluated PGx variants, and reviewed implications for medically complex neonates. METHODS A prospective cohort undergoing ES for nonimmune hydrops fetalis were offered PGx results as a secondary finding. Seven pharmacogenes with Level A evidence, defined by Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines, were tested and reported to patients and referring providers. Medication administration records were reviewed. RESULTS Most participants (36/40, 90%) desired PGx testing. 32/36 (89%) had potentially actionable PGx diplotypes in six genes: CYP2C19 (20/36, 56%), CYP2C9 (16/36, 44%), CYP2D6 (10/36, 28%), SLCO1B1 (13/36, 36%), TPMT (6/36, 17%), UGT1A1 (4/36, 11%). 12/13 (92%) live births had PGx variants. Neonatal chart review indicated that three medications with CPIC Level A evidence were administered to four neonates. None of the patients received a medication that aligned with an actionable pharmacogenetic variant as defined by Level A CPIC guidance. CONCLUSION Most participants opted to receive PGx results. 89% had actionable variants, consistent with population estimates. Obtaining fetal PGx data is feasible for medically complex neonates. Further studies are needed for broad clinical application of PGx in fetuses with major congenital abnormalities. Our study demonstrates the potential of PGx as useful preemptive clinical information that could be obtained at the time of fetal exome sequencing for other indications. CLINICALTRIALS gov Registration: NCT03911531.
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Affiliation(s)
- Megan Raymond
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth Critchlow
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephanie M Rice
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sascha Wodoslawsky
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Seth I Berger
- Center for Genetic Medicine Research at Children's National, Washington, DC, USA
| | | | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.
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13
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Crisamore KR, Empey PE, Pelletier JH, Clark RSB, Horvat CM. Patient-Specific Factors Associated with Dexmedetomidine Dose Requirements in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1753537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
AbstractThe objective of this study was to evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. A retrospective cross-sectional analysis of electronic health record-derived data spanning 10 years for patients admitted with a primary respiratory diagnosis at a quaternary children's hospital and who received a dexmedetomidine continuous infusion (n = 346 patients) was conducted. Penalized regression was used to select demographic, clinical, and medication characteristics associated with a median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/h (range: 0.1–1.8), median daily dose of 6.7 mcg/kg/d (range: 0.9–38.4), and median infusion duration of 1.6 days (range: 0.25–5.0). Of 26 variables tested, 15 were selected in the final model with days of dexmedetomidine infusion (β: 1.9; 95% confidence interval [CI]: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/d) (β: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/d) (β: 0.2; 95% CI: 0.1, 0.3), male sex (β: −1.1; 95% CI: −2.0, −0.2), and non-Black reported race (β: −1.2; 95% CI: −2.3, −0.08) significantly associated with median daily dexmedetomidine dose. Approximately 56% of dose variability was explained by the model. Readily obtainable information such as demographics, concomitant medications, and duration of infusion accounts for over half the variability in dexmedetomidine dosing. Identified factors, as well as additional environmental and genetic factors, warrant investigation in future studies to inform precision dosing strategies.
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Affiliation(s)
- Karryn R. Crisamore
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Jonathan H. Pelletier
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Robert S. B. Clark
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
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14
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Salloum RG, Bishop JR, Elchynski AL, Smith DM, Rowe E, Blake KV, Limdi NA, Aquilante CL, Bates J, Beitelshees AL, Cipriani A, Duong BQ, Empey PE, Formea CM, Hicks JK, Mroz P, Oslin D, Pasternak AL, Petry N, Ramsey LB, Schlichte A, Swain SM, Ward KM, Wiisanen K, Skaar TC, Van Driest SL, Cavallari LH, Tuteja S. Best-worst scaling methodology to evaluate constructs of the Consolidated Framework for Implementation Research: application to the implementation of pharmacogenetic testing for antidepressant therapy. Implement Sci Commun 2022; 3:52. [PMID: 35568931 PMCID: PMC9107643 DOI: 10.1186/s43058-022-00300-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Despite the increased demand for pharmacogenetic (PGx) testing to guide antidepressant use, little is known about how to implement testing in clinical practice. Best–worst scaling (BWS) is a stated preferences technique for determining the relative importance of alternative scenarios and is increasingly being used as a healthcare assessment tool, with potential applications in implementation research. We conducted a BWS experiment to evaluate the relative importance of implementation factors for PGx testing to guide antidepressant use. Methods We surveyed 17 healthcare organizations that either had implemented or were in the process of implementing PGx testing for antidepressants. The survey included a BWS experiment to evaluate the relative importance of Consolidated Framework for Implementation Research (CFIR) constructs from the perspective of implementing sites. Results Participating sites varied on their PGx testing platform and methods for returning recommendations to providers and patients, but they were consistent in ranking several CFIR constructs as most important for implementation: patient needs/resources, leadership engagement, intervention knowledge/beliefs, evidence strength and quality, and identification of champions. Conclusions This study demonstrates the feasibility of using choice experiments to systematically evaluate the relative importance of implementation determinants from the perspective of implementing organizations. BWS findings can inform other organizations interested in implementing PGx testing for mental health. Further, this study demonstrates the application of BWS to PGx, the findings of which may be used by other organizations to inform implementation of PGx testing for mental health disorders. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00300-7.
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Affiliation(s)
- Ramzi G Salloum
- University of Florida Clinical and Translational Science Institute, Gainesville, FL, USA.,University of Florida College of Medicine, Gainesville, FL, USA
| | - Jeffrey R Bishop
- University of Minnesota Medical School, Minneapolis, MN, USA.,University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | | | - D Max Smith
- MedStar Health, Georgetown University Medical Center, Washington, DC, USA
| | - Elizabeth Rowe
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Nita A Limdi
- University of Alabama Heersink School of Medicine, Birmingham, AL, USA
| | | | - Jill Bates
- Durham VA Healthcare System, Durham, NC, USA
| | | | - Amber Cipriani
- University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | - Philip E Empey
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | | | - Pawel Mroz
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Oslin
- Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA
| | - Amy L Pasternak
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Natasha Petry
- North Dakota State University/Sanford Health, Fargo, ND, USA
| | - Laura B Ramsey
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Sandra M Swain
- MedStar Health, Georgetown University Medical Center, Washington, DC, USA
| | - Kristen M Ward
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Larisa H Cavallari
- University of Florida Clinical and Translational Science Institute, Gainesville, FL, USA.,University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Smilow Center for Translational Research, 3400 Civic Center Boulevard, Bldg. 421 11th Floor, Room 143, Philadelphia, PA, 19104-5158, USA.
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15
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Formea CM, Schultz AJ, Empey PE. Pharmacists Closing Health Disparity Gaps through Pharmacogenomics. J Am Coll Clin Pharm 2022. [DOI: 10.1002/jac5.1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christine M. Formea
- Intermountain Healthcare, Department of Pharmacy Services Salt Lake City Utah
- Intermountain Precision Genomics, Intermountain Healthcare St. George Utah
| | - April J. Schultz
- Sanford Imagenetics, Sanford Health Sioux Falls South Dakota
- Sanford USD School of Medicine University of South Dakota Sioux Falls South Dakota
| | - Philip E. Empey
- School of Pharmacy University of Pittsburgh Pittsburgh Pennsylvania
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16
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Gammal RS, Lee YM, Petry NJ, Iwuchukwu O, Hoffman JM, Kisor DF, Empey PE. Pharmacists Leading the Way to Precision Medicine: Updates to the Core Pharmacist Competencies in Genomics. Am J Pharm Educ 2022; 86:8634. [PMID: 34301570 PMCID: PMC10159420 DOI: 10.5688/ajpe8634] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/23/2021] [Indexed: 05/06/2023]
Abstract
Genomics is becoming an increasingly important part of health care, and pharmacists are well-positioned to be practice-based leaders in pharmacogenomics and precision medicine. Competencies available through the Genetics/Genomics Competency Center provide a framework for pharmacogenomics instruction in both pharmacy school curricula and continuing education programs. Given the significant advancements in pharmacogenomics over the past decade, the 2019-2020 American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group updated the pharmacist competencies. The process used a systematic approach which included mapping pharmacogenomics-specific competencies to the entrustable professional activities for pharmacists and seeking consensus from key stakeholders. The result is an expansion to 30 competencies that reflect the contemporary roles pharmacists play in the application of pharmacogenomics in clinical practice. When implemented into curricula, these competencies will ensure that learners are "practice ready" to integrate pharmacogenomics into patient care. Additional postgraduate training is needed for advanced roles in pharmacogenomics implementation, education, and research.
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Affiliation(s)
- Roseann S Gammal
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts
| | - Yee Ming Lee
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Natasha J Petry
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- North Dakota State University, School of Pharmacy, Fargo, North Dakota
| | - Otito Iwuchukwu
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- Farleigh Dickinson University, School of Pharmacy, Florham Park, New Jersey
| | - James M Hoffman
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - David F Kisor
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- Manchester University, Fort Wayne, Indiana
| | - Philip E Empey
- American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group, Arlington, Virginia
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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17
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Beitelshees AL, Thomas CD, Empey PE, Stouffer GA, Angiolillo DJ, Franchi F, Tuteja S, Limdi NA, Lee JC, Duarte JD, Kreutz RP, Skaar TC, Coons JC, Giri J, McDonough CW, Rowland R, Stevenson JM, Thai T, Vesely MR, Wellen JT, Johnson JA, Winterstein AG, Cavallari LH, Lee CR. CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention in Diverse Clinical Settings. J Am Heart Assoc 2022; 11:e024159. [PMID: 35156424 PMCID: PMC9245803 DOI: 10.1161/jaha.121.024159] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Studies have demonstrated increased risk of major atherothrombotic events in CYP2C19 loss-of-function (LOF) variant carriers versus non-carriers treated with clopidogrel after percutaneous coronary intervention (PCI). We sought to evaluate real-world outcomes with the clinical implementation of CYP2C19-guided antiplatelet therapy after PCI. Methods and Results Data from 9 medical centers where genotyping was performed in the setting of PCI were included. Alternative therapy with prasugrel or ticagrelor was recommended for patients with a CYP2C19 LOF variant. The primary outcome was the composite of major atherothrombotic events (all-cause death, myocardial infarction, ischemic stroke, stent thrombosis, or hospitalization for unstable angina) within 12 months following PCI. Moderate or severe/life-threatening bleeding within 12 months was a secondary outcome. Among 3342 patients, 1032 (31%) were LOF carriers, of whom 571/1032 (55%) were treated with alternative therapy. In LOF carriers, the rate of major atherothrombotic events was lower in patients treated with alternative therapy versus clopidogrel (adjusted HR, 0.56; 95% CI 0.39-0.82). In those without a LOF allele, no difference was observed (adjusted HR, 1.07; 95% CI 0.71-1.60). There was no difference in bleeding with alternative therapy versus clopidogrel in either LOF carriers or those without a LOF allele. Conclusions Real-world data demonstrate lower atherothrombotic risk in CYP2C19 LOF carriers treated with alternative therapy versus clopidogrel and similar risk in those without a LOF allele treated with clopidogrel or alternative therapy. These data suggest that PCI patients treated with clopidogrel should undergo genotyping so that CYP2C19 LOF carriers can be identified and treated with alternative therapy.
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Affiliation(s)
- Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Philip E. Empey
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC
| | | | - Francesco Franchi
- University of Florida College of Medicine‐JacksonvilleJacksonvilleFL
| | - Sony Tuteja
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Nita A. Limdi
- Department of NeurologyProgram for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine InstituteSchool of MedicineUniversity of Alabama at BirminghamAL
| | - James C. Lee
- Department of Pharmacy PracticeUniversity of Illinois at ChicagoIL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | | | | | - James C. Coons
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - Jay Giri
- Cardiovascular Medicine DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Rachel Rowland
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - James M. Stevenson
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA,Division of Clinical PharmacologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Thuy Thai
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Jacob T. Wellen
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Craig R. Lee
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC,Division of Pharmacotherapy and Experimental TherapeuticsUNC Eshelman School of PharmacyUniversity of North Carolina at Chapel HillNC
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18
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Massart M, Berenbrok LA, Munro C, Berman NR, Empey PE. A Multidisciplinary Precision Medicine Service in Primary Care. Ann Fam Med 2022; 20:88. [PMID: 35074774 PMCID: PMC8786423 DOI: 10.1370/afm.2764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/12/2021] [Accepted: 05/24/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Lucas A Berenbrok
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | | | | | - Philip E Empey
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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19
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Coons JC, Stevenson JM, Patel A, Smith AJC, Prebehalla L, Empey PE. Antiplatelet Therapy and Bleeding Outcomes With CYP2C19 Genotyping. J Cardiovasc Pharmacol Ther 2022; 27:10742484221143246. [PMID: 36503270 DOI: 10.1177/10742484221143246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The impact of antiplatelet therapy with availability of CYP2C19 genotyping on bleeding in a real-world setting has not been extensively studied. METHODS Prospective, single-center, cohort study conducted between December 2015 and October 2019 with 1-year follow-up. Patients underwent percutaneous coronary intervention (PCI), CYP2C19 genotyping, and received P2Y12 inhibitor therapy. The primary outcome was time to first bleed of any severity using Bleeding Academic Research Consortium criteria. Secondary outcomes included time to first major bleed and rates of antiplatelet switching. RESULTS The primary outcome occurred in 697 of 2091 (33%) participants at a median of 15 days. Major bleeding occurred in 176 (8%) of patients. Compared to clopidogrel, treatment with ticagrelor or prasugrel was associated with increased risk of any bleeding (adjusted HR [aHR] 2.04, 95% CI 1.69-2.46). For patients without CYP2C19 no function alleles, treatment with prasugrel or ticagrelor was associated with increased risk of any bleeding (aHR 2.31, 95% CI 1.83-2.90). Similar associations were observed for major bleeding. No difference in ischemic events was observed. Among patients discharged on ticagrelor or prasugrel, 199 (36%) were de-escalated to clopidogrel within 1 year. De-escalation was more likely after a bleed if patients did not have a no function allele (35.9% vs 19.1%; P = .02). CONCLUSION Bleeding is common in post-PCI patients on antiplatelet therapy. Patients on high potency agents had higher bleeding risk in the population at-large and in non-carriers of CYP2C19 no function alleles. Genotype-guided antiplatelet de-escalation should be further explored in prospective studies.
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Affiliation(s)
- James C Coons
- Heart and Vascular Institute and Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - James M Stevenson
- Departments of Medicine and Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ami Patel
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - A J Conrad Smith
- Heart and Vascular Institute and Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Linda Prebehalla
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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20
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Gammal RS, Berenbrok LA, Empey PE, Massart MB. Documenting Pharmacogenomic Test Results in Electronic Health Records: Practical Considerations for Primary Care Teams. J Pers Med 2021; 11:jpm11121296. [PMID: 34945768 PMCID: PMC8706275 DOI: 10.3390/jpm11121296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 12/21/2022] Open
Abstract
With increasing patient interest in and access to pharmacogenomic testing, clinicians practicing in primary care are more likely than ever to encounter a patient seeking or presenting with pharmacogenomic test results. Gene-based prescribing recommendations are available to healthcare providers through Food and Drug Administration-approved drug labeling and Clinical Pharmacogenetics Implementation Consortium guidelines. Given the lifelong utility of pharmacogenomic test results to optimize pharmacotherapy for commonly prescribed medications, appropriate documentation of these results in a patient’s electronic health record (EHR) is essential. The current “gold standard” for pharmacogenomics implementation includes entering pharmacogenomic test results into EHRs as discrete results with associated clinical decision support (CDS) alerts that will fire at the point of prescribing, similar to drug allergy alerts. However, such infrastructure is limited to the few institutions that have invested in the resources and personnel to develop and maintain it. For the majority of clinicians who do not practice at an institution with a dedicated clinical pharmacogenomics team and integrated pharmacogenomics CDS in the EHR, this report provides practical tips for documenting pharmacogenomic test results in the problem list and allergy field to maximize the visibility and utility of results over time, especially when such results could prevent the occurrence of serious adverse drug reactions or predict therapeutic failure.
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Affiliation(s)
- Roseann S. Gammal
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA 02115, USA;
| | - Lucas A. Berenbrok
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA 15261, USA; (L.A.B.); (P.E.E.)
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA 15261, USA; (L.A.B.); (P.E.E.)
| | - Mylynda B. Massart
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Correspondence: ; Tel.: +1-503-939-7261
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21
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Tuteja S, Salloum RG, Elchynski AL, Smith DM, Rowe E, Blake KV, Limdi NA, Aquilante CL, Bates J, Beitelshees AL, Cipriani A, Duong BQ, Empey PE, Formea CM, Hicks JK, Mroz P, Oslin D, Pasternak AL, Petry N, Ramsey LB, Schlichte A, Swain SM, Ward KM, Wiisanen K, Skaar TC, Van Driest SL, Cavallari LH, Bishop JR. Multisite evaluation of institutional processes and implementation determinants for pharmacogenetic testing to guide antidepressant therapy. Clin Transl Sci 2021; 15:371-383. [PMID: 34562070 PMCID: PMC8841452 DOI: 10.1111/cts.13154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 12/11/2022] Open
Abstract
There is growing interest in utilizing pharmacogenetic (PGx) testing to guide antidepressant use, but there is lack of clarity on how to implement testing into clinical practice. We administered two surveys at 17 sites that had implemented or were in the process of implementing PGx testing for antidepressants. Survey 1 collected data on the process and logistics of testing. Survey 2 asked sites to rank the importance of Consolidated Framework for Implementation Research (CFIR) constructs using best‐worst scaling choice experiments. Of the 17 sites, 13 had implemented testing and four were in the planning stage. Thirteen offered testing in the outpatient setting, and nine in both outpatient/inpatient settings. PGx tests were mainly ordered by psychiatry (92%) and primary care (69%) providers. CYP2C19 and CYP2D6 were the most commonly tested genes. The justification for antidepressants selected for PGx guidance was based on Clinical Pharmacogenetics Implementation Consortium guidelines (94%) and US Food and Drug Administration (FDA; 75.6%) guidance. Both institutional (53%) and commercial laboratories (53%) were used for testing. Sites varied on the methods for returning results to providers and patients. Sites were consistent in ranking CFIR constructs and identified patient needs/resources, leadership engagement, intervention knowledge/beliefs, evidence strength and quality, and the identification of champions as most important for implementation. Sites deployed similar implementation strategies and measured similar outcomes. The process of implementing PGx testing to guide antidepressant therapy varied across sites, but key drivers for successful implementation were similar and may help guide other institutions interested in providing PGx‐guided pharmacotherapy for antidepressant management.
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Affiliation(s)
- Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ramzi G Salloum
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - D Max Smith
- MedStar Health, Georgetown University Medical Center, Washington, DC, USA
| | - Elizabeth Rowe
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Nita A Limdi
- University of Alabama School of Medicine, Birmingham, Alabama, USA
| | | | - Jill Bates
- Durham VA Healthcare System, Durham, North Carolina, USA
| | | | - Amber Cipriani
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | | | - Philip E Empey
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | | | | | - Pawel Mroz
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David Oslin
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Amy L Pasternak
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Natasha Petry
- North Dakota State University/Sanford Health, Fargo, North Dakota, USA
| | - Laura B Ramsey
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Sandra M Swain
- MedStar Health, Georgetown University Medical Center, Washington, DC, USA
| | - Kristen M Ward
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Kristin Wiisanen
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Jeffrey R Bishop
- University of Minnesota Medical School, Minneapolis, Minnesota, USA.,University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
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22
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Osier ND, Bramlett HM, Shear DA, Mondello S, Carlson SW, Dietrich WD, Deng-Bryant Y, Wang KKW, Hayes RL, Yang Z, Empey PE, Poloyac SM, Lafrenaye AD, Povlishock JT, Gilsdorf JS, Kochanek PM, Dixon CE. Kollidon VA64 Treatment in Traumatic Brain Injury: Operation Brain Trauma Therapy. J Neurotrauma 2021; 38:2454-2472. [PMID: 33843262 DOI: 10.1089/neu.2021.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Loss of plasmalemmal integrity may mediate cell death after traumatic brain injury (TBI). Prior studies in controlled cortical impact (CCI) indicated that the membrane resealing agent Kollidon VA64 improved histopathological and functional outcomes. Kollidon VA64 was therefore selected as the seventh therapy tested by the Operation Brain Trauma Therapy consortium, across three pre-clinical TBI rat models: parasagittal fluid percussion injury (FPI), CCI, and penetrating ballistic-like brain injury (PBBI). In each model, rats were randomized to one of four exposures (7-15/group): (1) sham; (2) TBI+vehicle; (3) TBI+Kollidon VA64 low-dose (0.4 g/kg); and (4) TBI+Kollidon VA64 high-dose (0.8 g/kg). A single intravenous VA64 bolus was given 15 min post-injury. Behavioral, histopathological, and serum biomarker outcomes were assessed over 21 days generating a 22-point scoring matrix per model. In FPI, low-dose VA64 produced zero points across behavior and histopathology. High-dose VA64 worsened motor performance compared with TBI-vehicle, producing -2.5 points. In CCI, low-dose VA64 produced intermediate benefit on beam balance and the Morris water maze (MWM), generating +3.5 points, whereas high-dose VA64 showed no effects on behavior or histopathology. In PBBI, neither dose altered behavior or histopathology. Regarding biomarkers, significant increases in glial fibrillary acidic protein (GFAP) levels were seen in TBI versus sham at 4 h and 24 h across models. Benefit of low-dose VA64 on GFAP was seen at 24 h only in FPI. Ubiquitin C-terminal hydrolase-L1 (UCH-L1) was increased in TBI compared with vehicle across models at 4 h but not at 24 h, without treatment effects. Overall, low dose VA64 generated +4.5 points (+3.5 in CCI) whereas high dose generated -2.0 points. The modest/inconsistent benefit observed reduced enthusiasm to pursue further testing.
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Affiliation(s)
- Nicole D Osier
- Holistic Adult Health Division, University of Texas at Austin, School of Nursing, Austin, Texas, USA
- Department of Neurology, University of Texas at Austin, Dell Medical School, Austin Texas, USA
| | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, Florida, USA
- Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection Program, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | | | - Shaun W Carlson
- Department of Neurological Surgery, Brain Trauma Research Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - W Dalton Dietrich
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ying Deng-Bryant
- Brain Trauma Neuroprotection Program, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics and Biomarkers Research, Department of Emergency Medicine, McKnight Brain Institute of the University of Florida, Gainesville, Florida, USA
| | - Ronald L Hayes
- Center for Innovative Research, Center for Proteomics and Biomarkers Research, Banyan Biomarkers, Inc., Alachua, Florida, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics and Biomarkers Research, Department of Emergency Medicine, McKnight Brain Institute of the University of Florida, Gainesville, Florida, USA
| | - Philip E Empey
- Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Samuel M Poloyac
- University of Texas Austin School of Pharmacy, Austin, Texas, USA
| | - Audrey D Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John T Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Janice S Gilsdorf
- Brain Trauma Neuroprotection Program, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Pediatrics, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, and UPMC Children's Hospital of Pittsburgh, Pittsburgh Pennsylvania, USA
| | - C Edward Dixon
- Department of Neurological Surgery, Brain Trauma Research Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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23
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Hicks JK, El Rouby N, Ong HH, Schildcrout JS, Ramsey LB, Shi Y, Tang LA, Aquilante CL, Beitelshees AL, Blake KV, Cimino JJ, Davis BH, Empey PE, Kao DP, Lemkin DL, Limdi NA, Lipori GP, Rosenman MB, Skaar TC, Teal E, Tuteja S, Wiley LK, Williams H, Winterstein AG, Van Driest SL, Cavallari LH, Peterson JF. Opportunity for Genotype-Guided Prescribing Among Adult Patients in 11 US Health Systems. Clin Pharmacol Ther 2021; 110:179-188. [PMID: 33428770 PMCID: PMC8217370 DOI: 10.1002/cpt.2161] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/24/2020] [Indexed: 12/11/2022]
Abstract
The value of utilizing a multigene pharmacogenetic panel to tailor pharmacotherapy is contingent on the prevalence of prescribed medications with an actionable pharmacogenetic association. The Clinical Pharmacogenetics Implementation Consortium (CPIC) has categorized over 35 gene-drug pairs as "level A," for which there is sufficiently strong evidence to recommend that genetic information be used to guide drug prescribing. The opportunity to use genetic information to tailor pharmacotherapy among adult patients was determined by elucidating the exposure to CPIC level A drugs among 11 Implementing Genomics In Practice Network (IGNITE)-affiliated health systems across the US. Inpatient and/or outpatient electronic-prescribing data were collected between January 1, 2011 and December 31, 2016 for patients ≥ 18 years of age who had at least one medical encounter that was eligible for drug prescribing in a calendar year. A median of ~ 7.2 million adult patients was available for assessment of drug prescribing per year. From 2011 to 2016, the annual estimated prevalence of exposure to at least one CPIC level A drug prescribed to unique patients ranged between 15,719 (95% confidence interval (CI): 15,658-15,781) in 2011 to 17,335 (CI: 17,283-17,386) in 2016 per 100,000 patients. The estimated annual exposure to at least 2 drugs was above 7,200 per 100,000 patients in most years of the study, reaching an apex of 7,660 (CI: 7,632-7,687) per 100,000 patients in 2014. An estimated 4,748 per 100,000 prescribing events were potentially eligible for a genotype-guided intervention. Results from this study show that a significant portion of adults treated at medical institutions across the United States is exposed to medications for which genetic information, if available, should be used to guide prescribing.
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Affiliation(s)
- J. Kevin Hicks
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nihal El Rouby
- Department of Pharmacotherapy & Translational Research, University of Florida, Gainesville, FL
- James Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH
| | - Henry H. Ong
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | | | - Laura B. Ramsey
- Department of Pediatrics, College of Medicine, University of Cincinnati, Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Leigh Anne Tang
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Christina L. Aquilante
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | | | | | - James J. Cimino
- Informatics Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Brittney H. Davis
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Philip E. Empey
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - David P. Kao
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Gloria P. Lipori
- University of Florida Health and University of Florida Health Sciences Center, Gainesville, FL
| | - Marc B. Rosenman
- Indiana University School of Medicine, Indianapolis, IN
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Todd C. Skaar
- Indiana University School of Medicine, Indianapolis, IN
| | | | - Sony Tuteja
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Laura K. Wiley
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, FL
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Larisa H. Cavallari
- Department of Pharmacotherapy & Translational Research, University of Florida, Gainesville, FL
| | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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24
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Empey PE, Pratt VM, Hoffman JM, Caudle KE, Klein TE. Expanding evidence leads to new pharmacogenomics payer coverage. Genet Med 2021; 23:830-832. [PMID: 33627827 DOI: 10.1038/s41436-021-01117-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James M Hoffman
- Office of Quality & Patient Care, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kelly E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Teri E Klein
- Department of Biomedical Data Science and Medicine, Stanford University, Stanford, CA, USA
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25
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Coons JC, Crisamore K, Adams S, Modany A, Simon MA, Zhao W, Shaik IH, Venkataramanan R, Empey PE. A pilot study of oral treprostinil pharmacogenomics and treatment persistence in patients with pulmonary arterial hypertension. Ther Adv Respir Dis 2021; 15:17534666211013688. [PMID: 33929912 PMCID: PMC8111525 DOI: 10.1177/17534666211013688] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIMS Treprostinil is a prostacyclin analog used to treat pulmonary arterial hypertension. Dosing is empiric and based on tolerability. Adverse effects are common and can affect treatment persistence. Pharmacogenomic variants that may affect treprostinil metabolism and transport have not been well-characterized. We aimed to investigate the pharmacogenomic sources of variability in treatment persistence and dosing. METHODS Patients were prospectively recruited from an IRB approved biobank registry at a single pulmonary hypertension center. A cohort of patients who received oral treprostinil were screened for participation. Pharmacogenomic analysis was for variants in CYP2C8, CYP2C9, and ABCC4. A retrospective review was conducted for demographics, clinical status, dosing, and response. Fisher's exact test was used for categorical data and Kruskal-Wallis test or Wilcoxon rank sum were used for continuous data. RESULTS A total of 15 patients received oral treprostinil and were consented. Their median age was 53 years, 73% were female, and 93% were White. The median total daily dose was 22.5 mg (13.5, 41) at last clinical observation. 40% of patients discontinued treatment with a majority due to adverse effects. Approximately 27% of patients had a loss-of-function variant in CYP2C8 (*1/*3 or *1/*4), whereas 47% of patients had a loss-of-function variant in CYP2C9 (*1/*2, *1/*3, or *2/*2). Minor allele frequencies for ABCC4 (rs1751034 and rs3742106) were 0.17 and 0.43, respectively. Survival analysis showed that increased CYP2C9 activity score was associated with decreased risk for treatment discontinuation [hazard ratio (HR): 0.13; 95% confidence interval (CI): 0.02, 0.91; p = 0.04]. Genetic variants were not significantly associated with dosing. CONCLUSION Genetic variants responsible for the metabolism and transport of oral treprostinil were common. Increased CYP2C9 activity score was associated with decreased risk for treatment discontinuation. However, dosing was not associated with genetic variants in metabolizing enzymes for treprostinil. Our findings suggest significant variability in treatment persistence to oral treprostinil, with pharmacogenomics being a potentially important contributor.The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- James C. Coons
- University of Pittsburgh School of Pharmacy, Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital, Salk Hall, Room 727, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Karryn Crisamore
- Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | | | - Marc A. Simon
- Bioengineering, and Clinical Translational Science, Department of Medicine/Division of Cardiology, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, Heart Failure Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wenchen Zhao
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Imam H. Shaik
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Philip E. Empey
- Pharmacogenomics Center of Excellence, Institute for Personalized Medicine, Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences and the Clinical and Translational Science Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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26
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Jha RM, Mondello S, Bramlett HM, Dixon CE, Shear DA, Dietrich WD, Wang KKW, Yang Z, Hayes RL, Poloyac SM, Empey PE, Lafrenaye AD, Yan HQ, Carlson SW, Povlishock JT, Gilsdorf JS, Kochanek PM. Glibenclamide Treatment in Traumatic Brain Injury: Operation Brain Trauma Therapy. J Neurotrauma 2020; 38:628-645. [PMID: 33203303 DOI: 10.1089/neu.2020.7421] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Glibenclamide (GLY) is the sixth drug tested by the Operation Brain Trauma Therapy (OBTT) consortium based on substantial pre-clinical evidence of benefit in traumatic brain injury (TBI). Adult Sprague-Dawley rats underwent fluid percussion injury (FPI; n = 45), controlled cortical impact (CCI; n = 30), or penetrating ballistic-like brain injury (PBBI; n = 36). Efficacy of GLY treatment (10-μg/kg intraperitoneal loading dose at 10 min post-injury, followed by a continuous 7-day subcutaneous infusion [0.2 μg/h]) on motor, cognitive, neuropathological, and biomarker outcomes was assessed across models. GLY improved motor outcome versus vehicle in FPI (cylinder task, p < 0.05) and CCI (beam balance, p < 0.05; beam walk, p < 0.05). In FPI, GLY did not benefit any other outcome, whereas in CCI, it reduced 21-day lesion volume versus vehicle (p < 0.05). On Morris water maze testing in CCI, GLY worsened performance on hidden platform latency testing versus sham (p < 0.05), but not versus TBI vehicle. In PBBI, GLY did not improve any outcome. Blood levels of glial fibrillary acidic protein and ubiquitin carboxyl terminal hydrolase-1 at 24 h did not show significant treatment-induced changes. In summary, GLY showed the greatest benefit in CCI, with positive effects on motor and neuropathological outcomes. GLY is the second-highest-scoring agent overall tested by OBTT and the only drug to reduce lesion volume after CCI. Our findings suggest that leveraging the use of a TBI model-based phenotype to guide treatment (i.e., GLY in contusion) might represent a strategic choice to accelerate drug development in clinical trials and, ultimately, achieve precision medicine in TBI.
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Affiliation(s)
- Ruchira M Jha
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Neurology, Neurobiology, and Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - C Edward Dixon
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - W Dalton Dietrich
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Ronald L Hayes
- Center for Innovative Research, Center for Proteomics and Biomarkers Research, Banyan Biomarkers, Inc., Alachua, Florida, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Audrey D Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hong Q Yan
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W Carlson
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John T Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Janice S Gilsdorf
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Pediatrics, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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27
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Gammal RS, Nguyen J, Audi E, Lee YM, Petry N, Empey PE. Advanced Pharmacy Practice Experiences in Pharmacogenomics Offered by US Pharmacy Programs. Am J Pharm Educ 2020; 84:ajpe8031. [PMID: 34283786 PMCID: PMC7779881 DOI: 10.5688/ajpe8031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 08/19/2020] [Indexed: 05/02/2023]
Abstract
Objective. To characterize advanced pharmacy practice experiences (APPEs) with a primary focus in pharmacogenomics at schools and colleges of pharmacy in the United States.Methods. This was a cross-sectional, multicenter, observational study of pharmacogenomics APPEs at US pharmacy schools. Directors of experiential education at 146 accredited schools of pharmacy were contacted by phone and asked if their school offered a pharmacogenomics APPE. The preceptors of pharmacogenomics APPEs identified by this phone screen were sent an email with a link to an online survey that asked about their APPE offerings.Results. Of the 142 schools of pharmacy that were successfully reached via phone, 40 (28%) offered an APPE with a primary focus in pharmacogenomics. Thirty unique APPEs with pharmacogenomics as a primary focus were identified. The total number of preceptors involved in the pharmacogenomics APPEs was 33: 19 (58%) faculty preceptors and 14 (42%) non-faculty preceptors. Twenty-three of the 30 pharmacogenomics APPEs completed the survey (77% response rate). The APPE sites were diverse and included academic medical centers, community health systems, pharmacogenomic testing laboratories, and schools of pharmacy. Each pharmacogenomics APPE accommodated an average of six students per year. The APPE activities varied across sites.Conclusion. Only a small number of US pharmacy schools offer an APPE with a primary focus in pharmacogenomics. These rotations are diverse in scope and precepted by faculty or non-faculty pharmacists. The Academy should pursue opportunities to increase experiential education in pharmacogenomics.
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Affiliation(s)
| | - Jenny Nguyen
- MCPHS University, School of Pharmacy, Boston, Massachusetts
| | - Elaina Audi
- MCPHS University, School of Pharmacy, Boston, Massachusetts
| | - Yee Ming Lee
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Natasha Petry
- North Dakota State University, School of Pharmacy, Fargo, North Dakota
| | - Philip E Empey
- University of Pittsburgh, School of Pharmacy, Pittsburgh, Pennsylvania
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Ramsey LB, Ong HH, Schildcrout JS, Shi Y, Tang LA, Hicks JK, El Rouby N, Cavallari LH, Tuteja S, Aquilante CL, Beitelshees AL, Lemkin DL, Blake KV, Williams H, Cimino JJ, Davis BH, Limdi NA, Empey PE, Horvat CM, Kao DP, Lipori GP, Rosenman MB, Skaar TC, Teal E, Winterstein AG, Owusu Obeng A, Salyakina D, Gupta A, Gruber J, McCafferty-Fernandez J, Bishop JR, Rivers Z, Benner A, Tamraz B, Long-Boyle J, Peterson JF, Van Driest SL. Prescribing Prevalence of Medications With Potential Genotype-Guided Dosing in Pediatric Patients. JAMA Netw Open 2020; 3:e2029411. [PMID: 33315113 PMCID: PMC7737091 DOI: 10.1001/jamanetworkopen.2020.29411] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Genotype-guided prescribing in pediatrics could prevent adverse drug reactions and improve therapeutic response. Clinical pharmacogenetic implementation guidelines are available for many medications commonly prescribed to children. Frequencies of medication prescription and actionable genotypes (genotypes where a prescribing change may be indicated) inform the potential value of pharmacogenetic implementation. OBJECTIVE To assess potential opportunities for genotype-guided prescribing in pediatric populations among multiple health systems by examining the prevalence of prescriptions for each drug with the highest level of evidence (Clinical Pharmacogenetics Implementation Consortium level A) and estimating the prevalence of potential actionable prescribing decisions. DESIGN, SETTING, AND PARTICIPANTS This serial cross-sectional study of prescribing prevalences in 16 health systems included electronic health records data from pediatric inpatient and outpatient encounters from January 1, 2011, to December 31, 2017. The health systems included academic medical centers with free-standing children's hospitals and community hospitals that were part of an adult health care system. Participants included approximately 2.9 million patients younger than 21 years observed per year. Data were analyzed from June 5, 2018, to April 14, 2020. EXPOSURES Prescription of 38 level A medications based on electronic health records. MAIN OUTCOMES AND MEASURES Annual prevalence of level A medication prescribing and estimated actionable exposures, calculated by combining estimated site-year prevalences across sites with each site weighted equally. RESULTS Data from approximately 2.9 million pediatric patients (median age, 8 [interquartile range, 2-16] years; 50.7% female, 62.3% White) were analyzed for a typical calendar year. The annual prescribing prevalence of at least 1 level A drug ranged from 7987 to 10 629 per 100 000 patients with increasing trends from 2011 to 2014. The most prescribed level A drug was the antiemetic ondansetron (annual prevalence of exposure, 8107 [95% CI, 8077-8137] per 100 000 children). Among commonly prescribed opioids, annual prevalence per 100 000 patients was 295 (95% CI, 273-317) for tramadol, 571 (95% CI, 557-586) for codeine, and 2116 (95% CI, 2097-2135) for oxycodone. The antidepressants citalopram, escitalopram, and amitriptyline were also commonly prescribed (annual prevalence, approximately 250 per 100 000 patients for each). Estimated prevalences of actionable exposures were highest for oxycodone and ondansetron (>300 per 100 000 patients annually). CYP2D6 and CYP2C19 substrates were more frequently prescribed than medications influenced by other genes. CONCLUSIONS AND RELEVANCE These findings suggest that opportunities for pharmacogenetic implementation among pediatric patients in the US are abundant. As expected, the greatest opportunity exists with implementing CYP2D6 and CYP2C19 pharmacogenetic guidance for commonly prescribed antiemetics, analgesics, and antidepressants.
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Affiliation(s)
- Laura B. Ramsey
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Henry H. Ong
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leigh Anne Tang
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J. Kevin Hicks
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nihal El Rouby
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville
- James Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville
| | - Sony Tuteja
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Daniel L. Lemkin
- Department of Emergency Medicine, University of Maryland, Baltimore
| | - Kathryn V. Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children’s Health System, Jacksonville, Florida
| | - Helen Williams
- Nemours Research Institute, Nemours Children’s Health System, Jacksonville, Florida
| | | | | | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christopher M. Horvat
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David P. Kao
- Department of Medicine, School of Medicine, University of Colorado, Aurora
| | - Gloria P. Lipori
- University of Florida Health and University of Florida Health Sciences Center, Gainesville
| | - Marc B. Rosenman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Todd C. Skaar
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine, Departments of Medicine and Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daria Salyakina
- Personalized Medicine Initiative, Nicklaus Children’s Health System, Miami, Florida
| | - Apeksha Gupta
- Personalized Medicine Initiative, Nicklaus Children’s Health System, Miami, Florida
| | - Joshua Gruber
- Personalized Medicine Initiative, Nicklaus Children’s Health System, Miami, Florida
| | | | - Jeffrey R. Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis
| | - Zach Rivers
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis
| | - Ashley Benner
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis
| | - Bani Tamraz
- School of Pharmacy, University of California, San Francisco
| | | | - Josh F. Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara L. Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Kochanek PM, Jackson TC, Jha RM, Clark RS, Okonkwo DO, Bayır H, Poloyac SM, Wagner AK, Empey PE, Conley YP, Bell MJ, Kline AE, Bondi CO, Simon DW, Carlson SW, Puccio AM, Horvat CM, Au AK, Elmer J, Treble-Barna A, Ikonomovic MD, Shutter LA, Taylor DL, Stern AM, Graham SH, Kagan VE, Jackson EK, Wisniewski SR, Dixon CE. Paths to Successful Translation of New Therapies for Severe Traumatic Brain Injury in the Golden Age of Traumatic Brain Injury Research: A Pittsburgh Vision. J Neurotrauma 2020; 37:2353-2371. [PMID: 30520681 PMCID: PMC7698994 DOI: 10.1089/neu.2018.6203] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
New neuroprotective therapies for severe traumatic brain injury (TBI) have not translated from pre-clinical to clinical success. Numerous explanations have been suggested in both the pre-clinical and clinical arenas. Coverage of TBI in the lay press has reinvigorated interest, creating a golden age of TBI research with innovative strategies to circumvent roadblocks. We discuss the need for more robust therapies. We present concepts for traditional and novel approaches to defining therapeutic targets. We review lessons learned from the ongoing work of the pre-clinical drug and biomarker screening consortium Operation Brain Trauma Therapy and suggest ways to further enhance pre-clinical consortia. Biomarkers have emerged that empower choice and assessment of target engagement by candidate therapies. Drug combinations may be needed, and it may require moving beyond conventional drug therapies. Precision medicine may also link the right therapy to the right patient, including new approaches to TBI classification beyond the Glasgow Coma Scale or anatomical phenotyping-incorporating new genetic and physiologic approaches. Therapeutic breakthroughs may also come from alternative approaches in clinical investigation (comparative effectiveness, adaptive trial design, use of the electronic medical record, and big data). The full continuum of care must also be represented in translational studies, given the important clinical role of pre-hospital events, extracerebral insults in the intensive care unit, and rehabilitation. TBI research from concussion to coma can cross-pollinate and further advancement of new therapies. Misconceptions can stifle/misdirect TBI research and deserve special attention. Finally, we synthesize an approach to deliver therapeutic breakthroughs in this golden age of TBI research.
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Affiliation(s)
- Patrick M. Kochanek
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Travis C. Jackson
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ruchira M. Jha
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Hülya Bayır
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samuel M. Poloyac
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Amy K. Wagner
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Philip E. Empey
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Yvette P. Conley
- Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Michael J. Bell
- Department of Critical Care Medicine, Children's National Medical Center, Washington, DC, USA
| | - Anthony E. Kline
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Corina O. Bondi
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dennis W. Simon
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W. Carlson
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Christopher M. Horvat
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alicia K. Au
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Amery Treble-Barna
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Milos D. Ikonomovic
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lori A. Shutter
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - D. Lansing Taylor
- University of Pittsburgh Drug Discovery Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew M. Stern
- Drug Discovery Institute, Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven H. Graham
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerian E. Kagan
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Edwin K. Jackson
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stephen R. Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - C. Edward Dixon
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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30
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Lee CR, Thomas CD, Beitelshees AL, Tuteja S, Empey PE, Lee JC, Limdi NA, Duarte JD, Skaar TC, Chen Y, Cook KJ, Coons JC, Dillon C, Franchi F, Giri J, Gong Y, Kreutz RP, McDonough CW, Stevenson JM, Weck KE, Angiolillo DJ, Johnson JA, Stouffer GA, Cavallari LH. Impact of the CYP2C19*17 Allele on Outcomes in Patients Receiving Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2020; 109:705-715. [PMID: 32897581 DOI: 10.1002/cpt.2039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/18/2020] [Indexed: 01/03/2023]
Abstract
Genotyping for CYP2C19 no function alleles to guide antiplatelet therapy after percutaneous coronary intervention (PCI) improves clinical outcomes. Although results for the increased function CYP2C19*17 allele are also reported, its clinical relevance in this setting remains unclear. A collaboration across nine sites examined antiplatelet therapy prescribing and clinical outcomes in 3,342 patients after implementation of CYP2C19-guided antiplatelet therapy. Risk of major atherothrombotic and bleeding events over 12 months after PCI were compared across cytochrome P450 2C19 isozyme (CYP2C19) metabolizer phenotype and antiplatelet therapy groups by proportional hazards regression. Clopidogrel was prescribed to a similar proportion of CYP2C19 normal (84.5%), rapid (82.9%), and ultrarapid metabolizers (80.6%) (P = 0.360). Clopidogrel-treated normal metabolizers (20.4 events/100 patient-years; adjusted hazard ratio (HR) 1.00, 95% confidence interval (CI), 0.75-1.33, P = 0.993) and clopidogrel-treated rapid or ultrarapid metabolizers (19.1 events/100 patient-years; adjusted HR 0.95, 95% CI, 0.69-1.30, P = 0.734) exhibited no difference in major atherothrombotic events compared with patients treated with prasugrel or ticagrelor (17.6 events/100 patient-years). In contrast, clopidogrel-treated intermediate and poor metabolizers exhibited significantly higher atherothrombotic event risk compared with prasugrel/ticagrelor-treated patients (adjusted HR 1.56, 95% CI, 1.12-2.16, P = 0.008). When comparing clopidogrel-treated rapid or ultrarapid metabolizers to normal metabolizers, no difference in atherothrombotic (adjusted HR 0.97, 95% CI, 0.73-1.29, P = 0.808) or bleeding events (adjusted HR 1.34, 95% CI, 0.83-2.17, P = 0.224) were observed. In a real-world setting of genotype-guided antiplatelet therapy, the CYP2C19*17 allele did not significantly impact post-PCI prescribing decisions or clinical outcomes. These results suggest the CYP2C19 *1/*17 and *17/*17 genotypes have limited clinical utility to guide antiplatelet therapy after PCI.
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Affiliation(s)
- Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip E Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nita A Limdi
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yiqing Chen
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James C Coons
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chrisly Dillon
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James M Stevenson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen E Weck
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
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McDonough CW, Breitenstein MK, Shahin M, Empey PE, Freimuth RR, Li L, Liebman M, Tuteja S. Translational Informatics Connects Real-World Information to Knowledge in an Increasingly Data-Driven World. Clin Pharmacol Ther 2020; 107:738-741. [PMID: 31837229 PMCID: PMC7678684 DOI: 10.1002/cpt.1719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/01/2019] [Indexed: 11/07/2022]
Affiliation(s)
| | | | | | | | | | - Lang Li
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | | | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Ginsburg GS, Madden E, Empey PE. Affiliate network members as force amplifiers of genomic medicine research. Per Med 2019; 16:431-433. [PMID: 31709897 DOI: 10.2217/pme-2019-0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Geoffrey S Ginsburg
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC 27708, USA
| | - Ebony Madden
- Division of Genomic Medicine, National Human Genome Research Institute (NHGRI), Bethesda, MD 20892, USA
| | - Philip E Empey
- University of Pittsburgh Medical Center (UPMC) Institute of Precision Medicine, University of Pittsburgh, Pittsburgh, PA 15213 USA
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33
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Uray T, Empey PE, Drabek T, Stezoski JP, Janesko-Feldman K, Jackson T, Garman RH, Kim F, Kochanek PM, Dezfulian C. Nitrite pharmacokinetics, safety and efficacy after experimental ventricular fibrillation cardiac arrest. Nitric Oxide 2019; 93:71-77. [PMID: 31526855 DOI: 10.1016/j.niox.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/12/2019] [Accepted: 09/10/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Besides therapeutic hypothermia or targeted temperature management no novel therapies have been developed to improve outcomes of patients after cardiac arrest (CA). Recent studies suggest that nitrite reduces neurological damage after asphyxial CA. Nitrite is also implicated as a new mediator of remote post conditioning produced by tourniquet inflation-deflation, which is under active investigation in CA. However, little is known about brain penetration or pharmacokinetics (PK). Therefore, to define the optimal use of this agent, studies on the PK of nitrite in experimental ventricular fibrillation (VF) are needed. We tested the hypothesis that nitrite administered after resuscitation from VF is detectable in cerebrospinal fluid (CSF), brain and other organ tissues, produces no adverse hemodynamic effects, and improves neurologic outcome in rats. METHODS After return of spontaneous circulation (ROSC) of 5 min untreated VF, adult male Sprague-Dawley rats were given intravenous nitrite (8 μM, 0.13 mg/kg) or placebo as a 5 min infusion beginning at 5 min after CA. Additionally, sham groups with and without nitrite treatment were also studied. Whole blood nitrite levels were serially measured. After 15 min, CSF, brain, heart and liver tissue were collected. In a second series, using a randomized and blinded treatment protocol, rats were treated with nitrite or placebo after arrest. Neurological deficit scoring (NDS) was performed daily and eight days after resuscitation, fear conditioning testing (FCT) and brain histology were assessed. RESULTS In an initial series of experiments, rats (n = 21) were randomized to 4 groups: VF-CPR and nitrite therapy (n = 6), VF-CPR and placebo therapy (n = 5), sham (n = 5), or sham plus nitrite therapy (n = 5). Whole blood nitrite levels increased during drug infusion to 57.14 ± 10.82 μM at 11 min post-resuscitation time (1 min after dose completion) in the VF nitrite group vs. 0.94 ± 0.58 μM in the VF placebo group (p < 0.001). There was a significant difference between the treatment and placebo groups in nitrite levels in blood between 7.5 and 15 min after CPR start and between groups with respect to nitrite levels in CSF, brain, heart and liver. In a second series (n = 25 including 5 shams), 19 out of 20 animals survived until day 8. However, NDS, FCT and brain histology did not show any statistically significant difference between groups. CONCLUSIONS Nitrite, administered early after ROSC from VF, was shown to cross the blood brain barrier after a 5 min VF cardiac arrest. We characterized the PK of intravenous nitrite administration after VF and were able to demonstrate nitrite safety in this feasibility study.
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Affiliation(s)
- Thomas Uray
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA; Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Philip E Empey
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh, PA, USA
| | - Tomas Drabek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Anesthesiology, University of Pittsburgh School of Medicine, PA, USA
| | - Jason P Stezoski
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA
| | - Travis Jackson
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA
| | - Robert H Garman
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis Kim
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA
| | - Cameron Dezfulian
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA; Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.
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Crisamore KR, Nolin TD, Coons JC, Empey PE. Engaging and Empowering Stakeholders to Advance Pharmacogenomics. Clin Pharmacol Ther 2019; 106:305-308. [PMID: 31241758 DOI: 10.1002/cpt.1470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/29/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Karryn R Crisamore
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James C Coons
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Institute for Precision Medicine, University of Pittsburgh and UPMC, Pittsburgh, Pennsylvania, USA
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Kochanek SJ, Close DA, Wang AX, Shun T, Empey PE, Eiseman JL, Johnston PA. Confirmation of Selected Synergistic Cancer Drug Combinations Identified in an HTS Campaign and Exploration of Drug Efflux Transporter Contributions to the Mode of Synergy. SLAS Discov 2019; 24:653-668. [PMID: 31039321 DOI: 10.1177/2472555219844566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Systematic unbiased high-throughput screening (HTS) of drug combinations (DCs) in well-characterized tumor cell lines is a data-driven strategy to identify novel DCs with potential to be developed into effective therapies. Four DCs from a DC HTS campaign were selected for confirmation; only one appears in clinicaltrials.gov and limited preclinical in vitro data indicates that the drug pairs interact synergistically. Nineteen DC-tumor cell line sets were confirmed to interact synergistically in three pharmacological interaction models. We developed an imaging assay to quantify accumulation of the ABCG2 efflux transporter substrate Hoechst. Gefitinib and raloxifene enhanced Hoechst accumulation in ABCG2 (BCRP)-expressing cells, consistent with inhibition of ABCG2 efflux. Both drugs also inhibit ABCB1 efflux. Mitoxantrone, daunorubicin, and vinorelbine are substrates of one or more of the ABCG2, ABCB1, or ABCC1 efflux transporters expressed to varying extents in the selected cell lines. Interactions between ABC drug efflux transporter inhibitors and substrates may have contributed to the observed synergy; however, other mechanisms may be involved. Novel synergistic DCs identified by HTS were confirmed in vitro, and plausible mechanisms of action studied. Similar approaches may justify the testing of novel HTS-derived DCs in mouse xenograft human cancer models and support the clinical evaluation of effective in vivo DCs in patients.
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Affiliation(s)
- Stanton J Kochanek
- 1 Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - David A Close
- 1 Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Allen Xinwei Wang
- 1 Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tongying Shun
- 2 University of Pittsburgh Drug Discovery Institute, Pittsburgh, PA, USA
| | - Philip E Empey
- 3 Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julie L Eiseman
- 4 University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA, USA.,5 Cancer Therapeutics Program, The University of Pittsburgh Cancer Institute, Hillman Cancer Center, Pittsburgh, PA, USA.,6 Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul A Johnston
- 1 Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,4 University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA, USA
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Berenbrok LA, Hart KM, McGrath SH, Coley KC, Somma McGivney MA, Empey PE. Community pharmacists' educational needs for implementing clinical pharmacogenomic services. J Am Pharm Assoc (2003) 2019; 59:539-544. [PMID: 31010787 DOI: 10.1016/j.japh.2019.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/09/2019] [Accepted: 03/08/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Pharmacist leadership and knowledge of pharmacogenomics is critical to the acceleration and enhancement of clinical pharmacogenomic services. This study aims for a qualitative description of community pharmacists' pharmacogenomic educational needs when implementing clinical pharmacogenomic services at community pharmacies. METHODS Pharmacists practicing at Rite Aid Pharmacy locations in the Greater Pittsburgh Area were recruited to participate in this qualitative analysis. Pharmacists from pharmacy locations offering pharmacogenomic testing and robust patient care services were eligible to participate in a semistructured, audio-recorded interview. The semistructured interview covered 4 domains crafted by the investigative team: (1) previous knowledge of pharmacogenomics; (2) implementation resources; (3) workflow adaptation; and (4) learning preferences. Interviews were transcribed verbatim and independently coded by 2 researchers. A thematic analysis by the investigative team followed. Supporting quotes were selected to illustrate each theme. RESULTS Eleven pharmacists from 9 unique pharmacy locations participated in this study. The average length of practice as a community pharmacist was 12 years (range, 1.5-31 years). Pharmacist's pharmacogenomic educational needs were categorized into 5 key themes: (1) enriched pharmacogenomic education and training; (2) active learning to build confidence in using pharmacogenomic data in practice; (3) robust and reputable clinical resources to effectively implement pharmacogenomic services; (4) team-based approach throughout implementation; (5) readily accessible network of pharmacogenomic experts. CONCLUSION This study describes the educational needs and preferences of community pharmacists for the successful provision of clinical pharmacogenomic services in community pharmacies. Pharmacists recognized their needs for enriched knowledge and instruction, practice applying pharmacogenomic principles with team-based approaches, robust clinical resources, and access to pharmacogenomic experts. This deeper understanding of pharmacist needs for pharmacogenomic education could help to accelerate and enhance the clinical implementation of pharmacogenomic services led by community pharmacists.
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Cavallari LH, Van Driest SL, Prows CA, Bishop JR, Limdi NA, Pratt VM, Ramsey LB, Smith DM, Tuteja S, Duong BQ, Hicks JK, Lee JC, Obeng AO, Beitelshees AL, Bell GC, Blake K, Crona DJ, Dressler L, Gregg RA, Hines LJ, Scott SA, Shelton RC, Weitzel KW, Johnson JA, Peterson JF, Empey PE, Skaar TC. Multi-site investigation of strategies for the clinical implementation of CYP2D6 genotyping to guide drug prescribing. Genet Med 2019; 21:2255-2263. [PMID: 30894703 PMCID: PMC6754805 DOI: 10.1038/s41436-019-0484-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/27/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose: A number of institutions have clinically implemented CYP2D6 genotyping to guide drug prescribing. We compared implementation strategies of early adopters of CYP2D6 testing, barriers faced by both early adopters and institutions in the process of implementing CYP2D6 testing, and approaches taken to overcome these barriers. Methods: We surveyed eight early adopters of CYP2D6 genotyping and eight institutions in the process of adoption. Data were collected on testing approaches, return of results procedures, applications of genotype results, challenges faced, and lessons learned. Results: Among early adopters, CYP2D6 testing was most commonly ordered to assist with opioid and antidepressant prescribing. Key differences among programs included test ordering and genotyping approaches, result reporting, and clinical decision support. However, all sites tested for copy number variation and 9 common variants, and reported results in the medical record. Most sites provided automatic consultation and had designated personnel to assist with genotype-informed therapy recommendations. Primary challenges were related to stakeholder support, CYP2D6 gene complexity, phenotype assignment, and sustainability. Conclusion: There are specific challenges unique to CYP2D6 testing given the complexity of the gene and its relevance to multiple medications. Consensus lessons learned may guide those interested in pursuing similar clinical pharmacogenetic programs.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA.
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cynthia A Prows
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Nita A Limdi
- Department of Neurology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura B Ramsey
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Sony Tuteja
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin Q Duong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Aniwaa Owusu Obeng
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Gillian C Bell
- Personalized Medicine Program, Mission Health, Asheville, NC, USA
| | - Kathryn Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Daniel J Crona
- Division of Pharmacotherapy and Experimental Therapeutics and Center for Pharmacogenomics and Individualized Therapy, University of North Carolina, Chapel Hill, NC, USA
| | - Lynn Dressler
- Personalized Medicine Program, Mission Health, Asheville, NC, USA
| | | | - Lindsay J Hines
- Department of Psychology, University of North Dakota, Grand Forks, ND; Sanford Brain and Spine Center and Sanford Imagenetics, Fargo, ND, USA
| | - Stuart A Scott
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY and Sema4, a Mount Sinai venture, Stamford, CT, USA
| | - Richard C Shelton
- Department of Psychiatry, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristin Wiisanen Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Josh F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN, USA
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Hagos FT, Adams SM, Poloyac SM, Kochanek PM, Horvat CM, Clark RSB, Empey PE. Membrane transporters in traumatic brain injury: Pathological, pharmacotherapeutic, and developmental implications. Exp Neurol 2019; 317:10-21. [PMID: 30797827 DOI: 10.1016/j.expneurol.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/15/2018] [Revised: 02/12/2019] [Accepted: 02/20/2019] [Indexed: 12/12/2022]
Abstract
Membrane transporters regulate the trafficking of endogenous and exogenous molecules across biological barriers and within the neurovascular unit. In traumatic brain injury (TBI), they moderate the dynamic movement of therapeutic drugs and injury mediators among neurons, endothelial cells and glial cells, thereby becoming important determinants of pathogenesis and effective pharmacotherapy after TBI. There are three ways transporters may impact outcomes in TBI. First, transporters likely play a key role in the clearance of injury mediators. Second, genetic association studies suggest transporters may be important in the transition of TBI from acute brain injury to a chronic neurological disease. Third, transporters dynamically control the brain penetration and efflux of many drugs and their distribution within and elimination from the brain, contributing to pharmacoresistance and possibly in some cases pharmacosensitivity. Understanding the nature of drugs or candidate drugs in development with respect to whether they are a transporter substrate or inhibitor is relevant to understand whether they distribute to their target in sufficient concentrations. Emerging data provide evidence of altered expression and function of transporters in humans after TBI. Genetic variability in expression and/or function of key transporters adds an additional dynamic, as shown in recent clinical studies. In this review, evidence supporting the role of individual membrane transporters in TBI are discussed as well as novel strategies for their modulation as possible therapeutic targets. Since data specifically targeting pediatric TBI are sparse, this review relies mainly on experimental studies using adult animals and clinical studies in adult patients.
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Affiliation(s)
- Fanuel T Hagos
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, PA, United States of America
| | - Solomon M Adams
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, PA, United States of America
| | - Samuel M Poloyac
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, PA, United States of America; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America
| | - Christopher M Horvat
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America
| | - Robert S B Clark
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Philip E Empey
- Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, PA, United States of America; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America.
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Coons JC, Patel R, Coley KC, Empey PE. Design and testing of Medivate, a mobile app to achieve medication list portability via Fast Healthcare Interoperability Resources. J Am Pharm Assoc (2003) 2019; 59:S78-S85.e2. [PMID: 30737102 DOI: 10.1016/j.japh.2019.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 12/19/2018] [Accepted: 01/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To describe the architecture, design, and testing of an innovative mobile application (Medivate) that facilities accurate sharing of medication lists with linked education. SETTING The deployment and testing of this app occurred in both the community and hospital settings in Pittsburgh, PA. PRACTICE INNOVATION Medivate is an iOS smartphone application and cloud architecture for patients and providers to keep medication and vaccine lists accurate by providing a method and tool to easily exchange these data. Medications are added directly to the app from the electronic health record (EHR) or by the patient manually. Quick response (QR) code technology is used to trigger the secure transfer and sharing of medications on demand via HL-7 Fast Healthcare Interoperability Resources-based data transfer. An iterative user-centered design process involving patients and student pharmacists practicing in community settings was used to develop and refine functionality. PRACTICE DESCRIPTION Adults with an iPhone were approached for participation in the design and evaluation of Medivate. Its functionality and integration into clinical workflow at hospital discharge or vaccine administration in the community were determined. EVALUATION In the community setting, interviews of pharmacists were conducted. In the hospital, metrics of study participation and experience with app deployment were determined. RESULTS The app was deployed in the community for patients that received vaccinations. Interviews provided insight into barriers and logistics for successful engagement. The app was integrated into hospital workflow and demonstrated interoperability with the inpatient EHR. Thirteen patients were provided the app before discharge. Engagement with the app was evident through medication list shares, education access, and changes to medication lists. Patients noted strong agreement with usefulness of the app to learn more about the purposes and adverse effects of medications prescribed. CONCLUSION A mobile app to achieve medication and vaccine list portability was successfully designed and integrated into the inpatient and community settings.
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Noc M, Friberg H, Huang CH, Empey PE. Therapeutic Hypothermia in Cardiac Arrest. Ther Hypothermia Temp Manag 2018; 8:195-198. [PMID: 30412452 DOI: 10.1089/ther.2018.29051.mjn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Marko Noc
- 1 Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Hans Friberg
- 2 Department of Emergency Medicine, Skane University Hospital, Lund University, Lund, Sweden
| | - Chien-Hua Huang
- 3 Department of Emergency Medicine, National Taiwan University, Medical College and Hospital, Taipei, Taiwan
| | - Philip E Empey
- 4 Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
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Jha RM, Koleck TA, Puccio AM, Okonkwo DO, Park SY, Zusman BE, Clark RSB, Shutter LA, Wallisch JS, Empey PE, Kochanek PM, Conley YP. Regionally clustered ABCC8 polymorphisms in a prospective cohort predict cerebral oedema and outcome in severe traumatic brain injury. J Neurol Neurosurg Psychiatry 2018; 89:1152-1162. [PMID: 29674479 PMCID: PMC6181785 DOI: 10.1136/jnnp-2017-317741] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/07/2018] [Accepted: 03/26/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVE ABCC8 encodes sulfonylurea receptor 1, a key regulatory protein of cerebral oedema in many neurological disorders including traumatic brain injury (TBI). Sulfonylurea-receptor-1 inhibition has been promising in ameliorating cerebral oedema in clinical trials. We evaluated whether ABCC8 tag single-nucleotide polymorphisms predicted oedema and outcome in TBI. METHODS DNA was extracted from 485 prospectively enrolled patients with severe TBI. 410 were analysed after quality control. ABCC8 tag single-nucleotide polymorphisms (SNPs) were identified (Hapmap, r2>0.8, minor-allele frequency >0.20) and sequenced (iPlex-Gold, MassArray). Outcomes included radiographic oedema, intracranial pressure (ICP) and 3-month Glasgow Outcome Scale (GOS) score. Proxy SNPs, spatial modelling, amino acid topology and functional predictions were determined using established software programs. RESULTS Wild-type rs7105832 and rs2237982 alleles and genotypes were associated with lower average ICP (β=-2.91, p=0.001; β=-2.28, p=0.003) and decreased radiographic oedema (OR 0.42, p=0.012; OR 0.52, p=0.017). Wild-type rs2237982 also increased favourable 3-month GOS (OR 2.45, p=0.006); this was partially mediated by oedema (p=0.03). Different polymorphisms predicted 3-month outcome: variant rs11024286 increased (OR 1.84, p=0.006) and wild-type rs4148622 decreased (OR 0.40, p=0.01) the odds of favourable outcome. Significant tag and concordant proxy SNPs regionally span introns/exons 2-15 of the 39-exon gene. CONCLUSIONS This study identifies four ABCC8 tag SNPs associated with cerebral oedema and/or outcome in TBI, tagging a region including 33 polymorphisms. In polymorphisms predictive of oedema, variant alleles/genotypes confer increased risk. Different variant polymorphisms were associated with favourable outcome, potentially suggesting distinct mechanisms. Significant polymorphisms spatially clustered flanking exons encoding the sulfonylurea receptor site and transmembrane domain 0/loop 0 (juxtaposing the channel pore/binding site). This, if validated, may help build a foundation for developing future strategies that may guide individualised care, treatment response, prognosis and patient selection for clinical trials.
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Affiliation(s)
- Ruchira Menka Jha
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Ava M Puccio
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Seo-Young Park
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin E Zusman
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lori A Shutter
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Wallisch
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip E Empey
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pharmacy and Therapeutics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yvette P Conley
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Human Genetics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
Pharmacogenomics is a tool for practitioners to provide precision pharmacotherapy using genomics. All providers are likely to encounter genomic data in practice with the expectation that they are able to successfully apply it to patient care. Pharmacogenomics tests for genetic variations in genes that are responsible for drug metabolism, transport, and targets of drug action. Variations can increase the risk for drug toxicity or poor efficacy. Pharmacogenomics can, therefore, be used to help select the best medication or aid in dosing. Nephrologists routinely treat cardiovascular disease and manage patients after kidney transplantation, two situations for which there are several high-evidence clinical recommendations for commonly used anticoagulants, antiplatelets, statins, and transplant medications. Successful use of pharmacogenomics in practice requires that providers are familiar with how to access and use pharmacogenomics resources. Similarly, clinical decision making related to whether to use existing data, whether to order testing, and if data should be used in practice is needed to deliver precision medicine. Pharmacogenomics is applicable to virtually every medical specialty, and nephrologists are well positioned to be implementation leaders.
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Affiliation(s)
| | | | - Philip E. Empey
- Department of Pharmacy and Therapeutics, School of Pharmacy, and
- Institute and of Precision Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Empey PE, Stevenson JM, Tuteja S, Weitzel KW, Angiolillo DJ, Beitelshees AL, Coons JC, Duarte JD, Franchi F, Jeng LJ, Johnson JA, Kreutz RP, Limdi NA, Maloney KA, Obeng AO, Peterson JF, Petry N, Pratt VM, Rollini F, Scott SA, Skaar TC, Vesely MR, Stouffer GA, Wilke RA, Cavallari LH, Lee CR. Multisite Investigation of Strategies for the Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy. Clin Pharmacol Ther 2018; 104:664-674. [PMID: 29280137 PMCID: PMC6019555 DOI: 10.1002/cpt.1006] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/27/2017] [Accepted: 12/20/2017] [Indexed: 01/05/2023]
Abstract
CYP2C19 genotype-guided antiplatelet therapy following percutaneous coronary intervention is increasingly implemented in clinical practice. However, challenges such as selecting a testing platform, communicating test results, building clinical decision support processes, providing patient and provider education, and integrating methods to support the translation of emerging evidence to clinical practice are barriers to broad adoption. In this report, we compare and contrast implementation strategies of 12 early adopters, describing solutions to common problems and initial performance metrics for each program. Key differences between programs included the test result turnaround time and timing of therapy changes, which are both related to the CYP2C19 testing model and platform used. Sites reported the need for new informatics infrastructure, expert clinicians such as pharmacists to interpret results, physician champions, and ongoing education. Consensus lessons learned are presented to provide a path forward for those seeking to implement similar clinical pharmacogenomics programs within their institutions.
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Affiliation(s)
- Philip E. Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Sony Tuteja
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kristin W. Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Dominick J. Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - James C. Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Julio D. Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Linda J.B. Jeng
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham AL
| | - Kristin A. Maloney
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai; and Pharmacy Department, The Mount Sinai Hospital, New York, NY
| | - Josh F. Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha Petry
- Department of Pharmacy Practice, North Dakota State University, Fargo, ND
| | - Victoria M. Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Fabiana Rollini
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Stuart A. Scott
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY and Sema4, a Mount Sinai venture, Stamford, CT
| | - Todd C. Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - George A. Stouffer
- Division of Cardiology, School of Medicine and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Russell A. Wilke
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Hagos FT, Empey PE, Wang P, Ma X, Poloyac SM, Bayır H, Kochanek PM, Bell MJ, Clark RSB. Exploratory Application of Neuropharmacometabolomics in Severe Childhood Traumatic Brain Injury. Crit Care Med 2018; 46:1471-1479. [PMID: 29742587 PMCID: PMC6095742 DOI: 10.1097/ccm.0000000000003203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To employ metabolomics-based pathway and network analyses to evaluate the cerebrospinal fluid metabolome after severe traumatic brain injury in children and the capacity of combination therapy with probenecid and N-acetylcysteine to impact glutathione-related and other pathways and networks, relative to placebo treatment. DESIGN Analysis of cerebrospinal fluid obtained from children enrolled in an Institutional Review Board-approved, randomized, placebo-controlled trial of a combination of probenecid and N-acetylcysteine after severe traumatic brain injury (Trial Registration NCT01322009). SETTING Thirty-six-bed PICU in a university-affiliated children's hospital. PATIENTS AND SUBJECTS Twelve children 2-18 years old after severe traumatic brain injury and five age-matched control subjects. INTERVENTION Probenecid (25 mg/kg) and N-acetylcysteine (140 mg/kg) or placebo administered via naso/orogastric tube. MEASUREMENTS AND MAIN RESULTS The cerebrospinal fluid metabolome was analyzed in samples from traumatic brain injury patients 24 hours after the first dose of drugs or placebo and control subjects. Feature detection, retention time, alignment, annotation, and principal component analysis and statistical analysis were conducted using XCMS-online. The software "mummichog" was used for pathway and network analyses. A two-component principal component analysis revealed clustering of each of the groups, with distinct metabolomics signatures. Several novel pathways with plausible mechanistic involvement in traumatic brain injury were identified. A combination of metabolomics and pathway/network analyses showed that seven glutathione-centered pathways and two networks were enriched in the cerebrospinal fluid of traumatic brain injury patients treated with probenecid and N-acetylcysteine versus placebo-treated patients. Several additional pathways/networks consisting of components that are known substrates of probenecid-inhibitable transporters were also identified, providing additional mechanistic validation. CONCLUSIONS This proof-of-concept neuropharmacometabolomics assessment reveals alterations in known and previously unidentified metabolic pathways and supports therapeutic target engagement of the combination of probenecid and N-acetylcysteine treatment after severe traumatic brain injury in children.
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Affiliation(s)
- Fanuel T. Hagos
- Center for Clinical Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Philip E. Empey
- Center for Clinical Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Pengcheng Wang
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, PA
| | - Xiaochao Ma
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, PA
| | - Samuel M. Poloyac
- Center for Clinical Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Hülya Bayır
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, Children’s National Health System, Washington, DC
| | - Robert S. B. Clark
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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45
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Kim F, Dezfulian C, Empey PE, Morrell M, Olsufka M, Scruggs S, Kudenchuk P, May S, Maynard C, Sayre MR, Nichol G. Usefulness of Intravenous Sodium Nitrite During Resuscitation for the Treatment of Out-of-Hospital Cardiac Arrest. Am J Cardiol 2018; 122:554-559. [PMID: 30205886 DOI: 10.1016/j.amjcard.2018.04.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/24/2018] [Accepted: 04/30/2018] [Indexed: 01/02/2023]
Abstract
It is hypothesized that intravenous (IV) sodium nitrite given during resuscitation of out-of-hospital cardiac arrest (OHCA) will improve survival. We performed a phase 1 open-label study of IV sodium nitrite given during resuscitation of 120 patents with OHCA from ventricular fibrillation or nonventricular fibrillation initial rhythms by Seattle Fire Department paramedics. A total of 59 patients received 25 mg (low) and 61 patients received 60 mg (high) of sodium nitrite during resuscitation from OHCA. Treatment effects were compared between high- and low-dose nitrite groups, and all patients in a concurrent local Emergency Medical Services registry of OHCA. Whole blood nitrite levels were measured in 97 patients. The rate of return of spontaneous circulation (48% vs 49%), rearrest in the field (15% vs 25%), use of norepinephrine (12% vs 12%), first systolic blood pressure (124 ± 32 vs 125 ± 38 mm Hg), survival to discharge (23.7% vs 16.4%), and neurologically favorable survival (18.6% vs 11.5%) were not significantly different in the low and high nitrite groups. There were no significant differences in these outcomes among patients who received IV nitrite compared with concurrent registry controls. We estimate that 60 mg achieves whole blood nitrite levels of 22 to 38 μM 10 minutes after administration, whereas 25 mg achieves a level of 9 to 16 μM 10 minutes after delivery. In conclusion, administration of IV nitrite is feasible and appears to be safe in patients with OHCA, permitting subsequent evaluation of the effectiveness of IV nitrite for the treatment of OHCA.
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Affiliation(s)
- Francis Kim
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington.
| | - Cameron Dezfulian
- Department of Critical Care Medicine, Safar Center for Resuscitation Research and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michele Olsufka
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Sue Scruggs
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Peter Kudenchuk
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Charles Maynard
- Department of Health Services, University of Washington, Seattle, Washington
| | - Michael R Sayre
- Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Graham Nichol
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington; Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Kochanek PM, Dixon CE, Mondello S, Wang KKK, Lafrenaye A, Bramlett HM, Dietrich WD, Hayes RL, Shear DA, Gilsdorf JS, Catania M, Poloyac SM, Empey PE, Jackson TC, Povlishock JT. Multi-Center Pre-clinical Consortia to Enhance Translation of Therapies and Biomarkers for Traumatic Brain Injury: Operation Brain Trauma Therapy and Beyond. Front Neurol 2018; 9:640. [PMID: 30131759 PMCID: PMC6090020 DOI: 10.3389/fneur.2018.00640] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 04/20/2018] [Accepted: 07/17/2018] [Indexed: 12/15/2022] Open
Abstract
Current approaches have failed to yield success in the translation of neuroprotective therapies from the pre-clinical to the clinical arena for traumatic brain injury (TBI). Numerous explanations have been put forth in both the pre-clinical and clinical arenas. Operation Brain Trauma Therapy (OBTT), a pre-clinical therapy and biomarker screening consortium has, to date, evaluated 10 therapies and assessed three serum biomarkers in nearly 1,500 animals across three rat models and a micro pig model of TBI. OBTT provides a unique platform to exploit heterogeneity of TBI and execute the research needed to identify effective injury specific therapies toward precision medicine. It also represents one of the first multi-center pre-clinical consortia for TBI, and through its work has yielded insight into the challenges and opportunities of this approach. In this review, important concepts related to consortium infrastructure, modeling, therapy selection, dosing and target engagement, outcomes, analytical approaches, reproducibility, and standardization will be discussed, with a focus on strategies to embellish and improve the chances for future success. We also address issues spanning the continuum of care. Linking the findings of optimized pre-clinical consortia to novel clinical trial designs has great potential to help address the barriers in translation and produce successes in both therapy and biomarker development across the field of TBI and beyond.
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Affiliation(s)
- Patrick M. Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - C. Edward Dixon
- Safar Center for Resuscitation Research, Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
- Oasi Research Institute (IRCCS), Troina, Italy
| | - Kevin K. K. Wang
- Program for Neuroproteomics and Biomarkers Research, Departments of Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, FL, United States
| | - Audrey Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, United States
| | - Helen M. Bramlett
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - W. Dalton Dietrich
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ronald L. Hayes
- Center for Innovative Research, Center for Neuroproteomics and Biomarkers Research, Banyan Biomarkers Research, Banyan Biomarkers, Inc., Alachua, FL, United States
| | - Deborah A. Shear
- Brain Trauma Neuroprotection and Neurorestoration Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Janice S. Gilsdorf
- Brain Trauma Neuroprotection and Neurorestoration Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | | | - Samuel M. Poloyac
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences and the Clinical Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Travis C. Jackson
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - John T. Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, United States
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Cavallari LH, Lee CR, Beitelshees AL, Cooper-DeHoff RM, Duarte JD, Voora D, Kimmel SE, McDonough CW, Gong Y, Dave CV, Pratt VM, Alestock TD, Anderson RD, Alsip J, Ardati AK, Brott BC, Brown L, Chumnumwat S, Clare-Salzler MJ, Coons JC, Denny JC, Dillon C, Elsey AR, Hamadeh IS, Harada S, Hillegass WB, Hines L, Horenstein RB, Howell LA, Jeng LJB, Kelemen MD, Lee YM, Magvanjav O, Montasser M, Nelson DR, Nutescu EA, Nwaba DC, Pakyz RE, Palmer K, Peterson JF, Pollin TI, Quinn AH, Robinson SW, Schub J, Skaar TC, Smith DM, Sriramoju VB, Starostik P, Stys TP, Stevenson JM, Varunok N, Vesely MR, Wake DT, Weck KE, Weitzel KW, Wilke RA, Willig J, Zhao RY, Kreutz RP, Stouffer GA, Empey PE, Limdi NA, Shuldiner AR, Winterstein AG, Johnson JA. Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 11:181-191. [PMID: 29102571 DOI: 10.1016/j.jcin.2017.07.022] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI). BACKGROUND CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI. METHODS After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights. RESULTS Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60). CONCLUSIONS These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Deepak Voora
- Department of Medicine, Center for Applied Genomics & Precision Medicine, Duke University, Durham, North Carolina
| | - Stephen E Kimmel
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - R David Anderson
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Jorge Alsip
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amer K Ardati
- Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Brigitta C Brott
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lawrence Brown
- Veterans Administration Medical Center, Baltimore, Maryland
| | - Supatat Chumnumwat
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Michael J Clare-Salzler
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - James C Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua C Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Issam S Hamadeh
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Shuko Harada
- Department of Pathology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - William B Hillegass
- Heart South Cardiovascular Group, Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Hines
- Department of Neuropsychology, University of North Dakota, Fargo, North Dakota
| | | | - Lucius A Howell
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda J B Jeng
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Mark D Kelemen
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Yee Ming Lee
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Oyunbileg Magvanjav
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - May Montasser
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - David R Nelson
- College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois; Department of Pharmacy Systems, Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Devon C Nwaba
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Ruth E Pakyz
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Kathleen Palmer
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Josh F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni I Pollin
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Alison H Quinn
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Shawn W Robinson
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Jamie Schub
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Todd C Skaar
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Vindhya B Sriramoju
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Tomasz P Stys
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James M Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nicholas Varunok
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark R Vesely
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Karen E Weck
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Russell A Wilke
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James Willig
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Y Zhao
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nita A Limdi
- Department of Neurology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan R Shuldiner
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida; Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
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Jha RM, Puccio AM, Okonkwo DO, Zusman BE, Park SY, Wallisch J, Empey PE, Shutter LA, Clark RSB, Kochanek PM, Conley YP. ABCC8 Single Nucleotide Polymorphisms are Associated with Cerebral Edema in Severe TBI. Neurocrit Care 2017; 26:213-224. [PMID: 27677908 DOI: 10.1007/s12028-016-0309-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cerebral edema (CE) in traumatic brain injury (TBI) is the consequence of multiple underlying mechanisms and is associated with unfavorable outcomes. Genetic variability in these pathways likely explains some of the clinical heterogeneity observed in edema development. A role for sulfonylurea receptor-1 (Sur1) in CE is supported. However, there are no prior studies examining the effect of genetic variability in the Sur1 gene (ABCC8) on the development of CE. We hypothesize that ABCC8 single nucleotide polymorphisms (SNPs) are predictive of CE. METHODS DNA was extracted from 385 patients. SNPs in ABCC8 were genotyped using the Human Core Exome v1.2 (Illumina). CE measurements included acute CT edema, mean and peak intracranial pressure (ICP), and need for decompressive craniotomy. RESULTS Fourteen SNPs with minor allele frequency >0.2 were identified. Four SNPS rs2283261, rs3819521, rs2283258, and rs1799857 were associated with CE measures. In multiple regression models, homozygote-variant genotypes in rs2283261, rs3819521, and rs2283258 had increased odds of CT edema (OR 2.45, p = 0.007; OR 2.95, p = 0.025; OR 3.00, p = 0.013), had higher mean (β = 3.13, p = 0.000; β = 2.95, p = 0.005; β = 3.20, p = 0.008), and peak ICP (β = 8.00, p = 0.001; β = 7.64, p = 0.007; β = 6.89, p = 0.034). The homozygote wild-type genotype of rs1799857 had decreased odds of decompressive craniotomy (OR 0.47, p = 0.004). CONCLUSIONS This is the first report assessing the impact of ABCC8 genetic variability on CE development in TBI. Minor allele ABCC8 SNP genotypes had increased risk of CE, while major SNP alleles were protective-potentially suggesting an evolutionary advantage. These findings could guide risk stratification, treatment responders, and the development of novel targeted or gene-based therapies against CE in TBI and other neurological disorders.
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Affiliation(s)
- Ruchira M Jha
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA. .,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Ava M Puccio
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David O Okonkwo
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin E Zusman
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Seo-Young Park
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica Wallisch
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lori A Shutter
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Anesthesiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Anesthesiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yvette P Conley
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
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49
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Adams SM, Conley YP, Wagner AK, Jha RM, Clark RSB, Poloyac SM, Kochanek PM, Empey PE. The pharmacogenomics of severe traumatic brain injury. Pharmacogenomics 2017; 18:1413-1425. [PMID: 28975867 PMCID: PMC5694019 DOI: 10.2217/pgs-2017-0073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/06/2017] [Indexed: 01/08/2023] Open
Abstract
Pharmacotherapy for traumatic brain injury (TBI) is focused on resuscitation, prevention of secondary injury, rehabilitation and recovery. Pharmacogenomics may play a role in TBI for predicting therapies for sedation, analgesia, seizure prevention, intracranial pressure-directed therapy and neurobehavioral/psychiatric symptoms. Research into genetic predictors of outcomes and susceptibility to complications may also help clinicians to tailor therapeutics for high-risk individuals. Additionally, the expanding use of genomics in the drug development pipeline has provided insight to novel investigational and repurposed medications that may be useful in the treatment of TBI and its complications. Genomics in the context of treatment and prognostication for patients with TBI is a promising area for clinical progress of pharmacogenomics.
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Affiliation(s)
- Solomon M Adams
- Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Yvette P Conley
- Health Promotion & Development, School of Nursing, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Amy K Wagner
- Department of Physical Medicine & Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Ruchira M Jha
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15224, USA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Robert SB Clark
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15224, USA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Patrick M Kochanek
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15224, USA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Philip E Empey
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15224, USA
- Department of Pharmacy & Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Adams SM, Conley YP, Ren D, Okonkwo DO, Puccio AM, Dixon CE, Clark RSB, Kochanek PM, Empey PE. ABCG2 c.421C>A Is Associated with Outcomes after Severe Traumatic Brain Injury. J Neurotrauma 2017; 35:48-53. [PMID: 28747144 DOI: 10.1089/neu.2017.5000] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death with no pharmacological treatments that improve outcomes. Transporter proteins participate in TBI recovery by maintaining the central nervous system (CNS) biochemical milieu. Genetic variations in transporters that alter expression and/or function have been associated with TBI outcomes. The ATP-binding cassette transporter, ABCG2, is a uric acid (UA) transporter that effluxes UA from cells in the CNS and is responsible for systemic UA clearance. Uric acid is a CNS antioxidant and/or a biomarker that might support TBI recovery. Our objective was to investigate the impact of ABCG2 SNP: c.421C>A on TBI outcomes. Two cohorts (discovery [N = 270] and replication [N = 166]) were genotyped for ABCG2 c.421C>A. Glasgow Outcome Scale (GOS) scores were collected at 3, 6, 12, and 24 months post-injury and compared with mixed-effects multiple ordinal regression controlled for time post-injury, age, sex, time, post-injury imaging determined hemorrhage types, and Glasgow Coma Scale score. Variant alleles (genotype) were associated with better GOS scores (p = 0.01 [discovery] and p = 0.02 [replication]), whereas genotype*age interaction was associated with worse GOS scores (p = 0.03 [discovery] and p = 0.01 [replication]). Reversed coefficient directionality suggests variant allele(s) are protective up to approximately age 34 years. Overall, variant alleles at ABCG2 c.421C>A associate with better GOS scores post-injury in two independently sampled cohorts. This finding is mitigated by increasing subject age. This suggests that ABCG2 might have an age-dependent effect on TBI recovery and should be explored in future mechanistic studies.
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Affiliation(s)
- Solomon M Adams
- 1 Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Yvette P Conley
- 2 Health Promotion and Development, School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania.,3 Human Genetics, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Dianxu Ren
- 4 Health and Community Systems, School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 5 Neurological Surgery, School of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Ava M Puccio
- 5 Neurological Surgery, School of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - C Edward Dixon
- 5 Neurological Surgery, School of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,6 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Robert S B Clark
- 6 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 6 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Philip E Empey
- 6 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania.,7 Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
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