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Mosley JD, Shelley JP, Dickson AL, Zanussi J, Daniel LL, Zheng NS, Bastarache L, Wei WQ, Shi M, Jarvik GP, Rosenthal EA, Khan A, Sherafati A, Kullo IJ, Walunas TL, Glessner J, Hakonarson H, Cox NJ, Roden DM, Frangakis SG, Vanderwerff B, Stein CM, Van Driest SL, Borinstein SC, Shu XO, Zawistowski M, Chung CP, Kawai VK. Clinical associations with a polygenic predisposition to benign lower white blood cell counts. Nat Commun 2024; 15:3384. [PMID: 38649760 PMCID: PMC11035609 DOI: 10.1038/s41467-024-47804-5] [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: 08/20/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024] Open
Abstract
Polygenic variation unrelated to disease contributes to interindividual variation in baseline white blood cell (WBC) counts, but its clinical significance is uncharacterized. We investigated the clinical consequences of a genetic predisposition toward lower WBC counts among 89,559 biobank participants from tertiary care centers using a polygenic score for WBC count (PGSWBC) comprising single nucleotide polymorphisms not associated with disease. A predisposition to lower WBC counts was associated with a decreased risk of identifying pathology on a bone marrow biopsy performed for a low WBC count (odds-ratio = 0.55 per standard deviation increase in PGSWBC [95%CI, 0.30-0.94], p = 0.04), an increased risk of leukopenia (a low WBC count) when treated with a chemotherapeutic (n = 1724, hazard ratio [HR] = 0.78 [0.69-0.88], p = 4.0 × 10-5) or immunosuppressant (n = 354, HR = 0.61 [0.38-0.99], p = 0.04). A predisposition to benign lower WBC counts was associated with an increased risk of discontinuing azathioprine treatment (n = 1,466, HR = 0.62 [0.44-0.87], p = 0.006). Collectively, these findings suggest that there are genetically predisposed individuals who are susceptible to escalations or alterations in clinical care that may be harmful or of little benefit.
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Affiliation(s)
- Jonathan D Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - John P Shelley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jacy Zanussi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L Daniel
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Neil S Zheng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gail P Jarvik
- Department of Genome Sciences, University of Washington Medical Center, Seattle, WA, USA
- Department of Medicine (Medical Genetics), University of Washington Medical Center, Seattle, WA, USA
| | - Elisabeth A Rosenthal
- Department of Medicine (Medical Genetics), University of Washington Medical Center, Seattle, WA, USA
| | - Atlas Khan
- Division of Nephrology, Dept of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Alborz Sherafati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Iftikhar J Kullo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Theresa L Walunas
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph Glessner
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy J Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan G Frangakis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brett Vanderwerff
- Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, MI, USA
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott C Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiao-Ou Shu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Matthew Zawistowski
- Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, MI, USA
| | | | - Vivian K Kawai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Liu M, Hernandez S, Aquilante CL, Deininger KM, Lindenfeld J, Schlendorf KH, Van Driest SL. Composite CYP3A (CYP3A4 and CYP3A5) phenotypes and influence on tacrolimus dose adjusted concentrations in adult heart transplant recipients. Pharmacogenomics J 2024; 24:4. [PMID: 38360955 DOI: 10.1038/s41397-024-00325-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/18/2024] [Accepted: 01/31/2024] [Indexed: 02/17/2024]
Abstract
CYP3A5 genetic variants are associated with tacrolimus metabolism. Controversy remains on whether CYP3A4 increased [*1B (rs2740574), *1 G (rs2242480)] and decreased function [*22 (rs35599367)] genetic variants provide additional information. This retrospective cohort study aims to address whether tacrolimus dose-adjusted trough concentrations differ between combined CYP3A (CYP3A5 and CYP3A4) phenotype groups. Heart transplanted patients (n = 177, between 2008 and 2020) were included and median age was 54 years old. Significant differences between CYP3A phenotype groups in tacrolimus dose-adjusted trough concentrations were found in the early postoperative period and continued to 6 months post-transplant. In CYP3A5 nonexpressers, carriers of CYP3A4*1B or *1 G variants (Group 3) compared to CYP3A4*1/*1 (Group 2) patients were found to have lower tacrolimus dose-adjusted trough concentrations at 2 months. In addition, significant differences were found among CYP3A phenotype groups in the dose at discharge and time to therapeutic range while time in therapeutic range was not significantly different. A combined CYP3A phenotype interpretation may provide more nuanced genotype-guided TAC dosing in heart transplant recipients.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Savine Hernandez
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Joann Lindenfeld
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly H Schlendorf
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Division of General Pediatrics, Department of Pediatrics, and Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Lubarsky D, Van Driest SL, Crum K, Fountain D, Kannankeril PJ. Association Between Neighborhood Socioeconomic Factors and Length of Stay After Surgery for Congenital Heart Disease. Pediatr Crit Care Med 2024:00130478-990000000-00298. [PMID: 38299943 DOI: 10.1097/pcc.0000000000003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Neighborhood socioeconomic status, as measured by area deprivation index (ADI) is associated with longer length of stay (LOS) after surgery for hypoplastic left heart syndrome. We tested the hypothesis that LOS is associated with ADI in a large cohort of congenital heart disease (CHD) surgical cases of varying severity and sought to determine which other components of the ADI accounted for any associations. DESIGN Retrospective analysis of a curated dataset. The Brokamp ADI was determined using residential addresses. Overall, ADI and each of its six individual components were dichotomized, and LOS compared between groups above versus below the median for the entire cohort and after stratifying by surgical The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) severity category. SETTING Single-center academic pediatric teaching hospital. PATIENTS CHD patients who underwent surgical repair/palliation between September 2007 and August 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 2462 patients (52.7% male) were included. Median age was 254 (interquartile range [IQR] 95-1628) days and median LOS in the hospital was 8 (IQR 5-18) days. We failed to identify an association between Brokamp ADI, above versus below the median for the entire cohort, and LOS; nor in STAT categories 1-4. However, in STAT category 5 (n = 129) those with ADI above the median (more deprived) had a significantly longer LOS (48 [20-88] vs. 36 [18-49] d, p = 0.034). Of the individual components of the ADI, only percent below poverty level and percent vacant houses were associated with LOS in STAT category 5. CONCLUSIONS LOS after CHD surgery is associated with Brokamp ADI in STAT category 5 cases, we failed to identify an association in lower-risk cardiac operations.
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Affiliation(s)
- Daniel Lubarsky
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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Grabowska ME, Van Driest SL, Robinson JR, Patrick AE, Guardo C, Gangireddy S, Ong HH, Feng Q, Carroll R, Kannankeril PJ, Wei WQ. Developing and evaluating pediatric phecodes (Peds-Phecodes) for high-throughput phenotyping using electronic health records. J Am Med Inform Assoc 2024; 31:386-395. [PMID: 38041473 PMCID: PMC10797257 DOI: 10.1093/jamia/ocad233] [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: 08/22/2023] [Revised: 10/04/2023] [Accepted: 11/20/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVE Pediatric patients have different diseases and outcomes than adults; however, existing phecodes do not capture the distinctive pediatric spectrum of disease. We aim to develop specialized pediatric phecodes (Peds-Phecodes) to enable efficient, large-scale phenotypic analyses of pediatric patients. MATERIALS AND METHODS We adopted a hybrid data- and knowledge-driven approach leveraging electronic health records (EHRs) and genetic data from Vanderbilt University Medical Center to modify the most recent version of phecodes to better capture pediatric phenotypes. First, we compared the prevalence of patient diagnoses in pediatric and adult populations to identify disease phenotypes differentially affecting children and adults. We then used clinical domain knowledge to remove phecodes representing phenotypes unlikely to affect pediatric patients and create new phecodes for phenotypes relevant to the pediatric population. We further compared phenome-wide association study (PheWAS) outcomes replicating known pediatric genotype-phenotype associations between Peds-Phecodes and phecodes. RESULTS The Peds-Phecodes aggregate 15 533 ICD-9-CM codes and 82 949 ICD-10-CM codes into 2051 distinct phecodes. Peds-Phecodes replicated more known pediatric genotype-phenotype associations than phecodes (248 vs 192 out of 687 SNPs, P < .001). DISCUSSION We introduce Peds-Phecodes, a high-throughput EHR phenotyping tool tailored for use in pediatric populations. We successfully validated the Peds-Phecodes using genetic replication studies. Our findings also reveal the potential use of Peds-Phecodes in detecting novel genotype-phenotype associations for pediatric conditions. We expect that Peds-Phecodes will facilitate large-scale phenomic and genomic analyses in pediatric populations. CONCLUSION Peds-Phecodes capture higher-quality pediatric phenotypes and deliver superior PheWAS outcomes compared to phecodes.
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Affiliation(s)
- Monika E Grabowska
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Sara L Van Driest
- Department of Pediatrics and the Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Jamie R Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Anna E Patrick
- Department of Pediatrics and the Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Chris Guardo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Srushti Gangireddy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Henry H Ong
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - QiPing Feng
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Robert Carroll
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Prince J Kannankeril
- Department of Pediatrics and the Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
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Patterson SG, Lamb CK, Gong W, Resser J, Lindsell CJ, Van Driest SL, Stark RJ. Pediatric Persistent Inflammation, Immunosuppression, and Catabolism Syndrome Prevalence in Sepsis-Related Mortalities: A 23-Year Institutional History. Chest 2023; 164:1204-1215. [PMID: 37164130 PMCID: PMC10635837 DOI: 10.1016/j.chest.2023.05.002] [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: 10/20/2022] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Delayed mortality in sepsis often is linked to a lack of resolution in the inflammatory cascade termed persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Limited research exists on PICS in pediatric patients with sepsis. RESEARCH QUESTION What is the prevalence of pediatric PICS (pPICS) in patients who died of sepsis-related causes and what associated pathogen profiles and comorbidities did they have compared with those patients without pPICS who died from sepsis? STUDY DESIGN AND METHODS A retrospective study of a single institution using a de-identified database from 1997 through 2020 for all patients aged 21 years or younger who died of culture-positive sepsis from a known source and who had laboratory data available were evaluated for the presence of pPICS. RESULTS Among records extracted from the institutional database, 557 patients had culture-positive sepsis, with 262 patients having pPICS (47%). Patients with pPICS were more likely to have underlying hematologic or oncologic disease or cardiac disease. In addition, patients who had pPICS showed increased odds of associated fungal infection compared with those patients who did not (OR, 2.69; 95% CI, 1.59-4.61; P < .001). When assessing laboratory criteria, having a sustained absolute lymphocyte count of < 1.0 × 103/μL was most closely associated with having pPICS compared with other laboratory parameters. Finally, the results of multivariate logistic regression analysis indicated that patients with pPICS were more common in the cardiac ICU, as opposed to the PICU (OR, 3.43; CI, 1.57-7.64; P = .002). INTERPRETATION Pediatric patients who died of a sepsis-related cause have a pPICS phenotype nearly one-half of the time. These patients are more likely to be in the cardiac ICU than the pediatric ICU and have associated fungal infections. Special attention should be directed toward this population in future research.
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Affiliation(s)
| | - Celia K Lamb
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Wu Gong
- Department of Biostatistics and Bioinformatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jackson Resser
- Department of Biostatistics and Bioinformatics, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher J Lindsell
- Division of Biostatistics, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Sara L Van Driest
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan J Stark
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
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Roland D, Van Driest SL, Heerman WJ, King KY, Maitre NL, Fritz SA, Barkin S. Navigating success for early stage investigators-practical words of advice. Pediatr Res 2023; 94:1248. [PMID: 32555500 DOI: 10.1038/s41390-020-0949-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Damian Roland
- SAPPHIRE, Health Sciences, University of Leicester, Leicester, UK.
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK.
| | - Sara L Van Driest
- Department of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William J Heerman
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katharine Y King
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Nathalie L Maitre
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Stephanie A Fritz
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Shari Barkin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Schuler BA, Bastarache L, Wang J, He J, Van Driest SL, Denny JC. Population genetic testing and SERPINA1 sequencing identifies unidentified alpha-1 antitrypsin deficiency alleles and gene-environment interaction with hepatitis C infection. PLoS One 2023; 18:e0286469. [PMID: 37651384 PMCID: PMC10470904 DOI: 10.1371/journal.pone.0286469] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 09/02/2023] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD), a relatively common autosomal recessive genetic disorder, is underdiagnosed in symptomatic individuals. We sought to compare the risk of liver transplantation associated with hepatitis C infection with AATD heterozygotes and homozygotes and determine if SERPINA1 sequencing would identify undiagnosed AATD. We performed a retrospective cohort study in a deidentified Electronic Health Record (EHR)-linked DNA biobank with 72,027 individuals genotyped for the M, Z, and S alleles in SERPINA1. We investigated liver transplantation frequency by genotype group and compared with hepatitis C infection. We performed SERPINA1 sequencing in carriers of pathogenic AATD alleles who underwent liver transplantation. Liver transplantation was associated with the Z allele (ZZ: odds ratio [OR] = 1.31, p<2e-16; MZ: OR = 1.02, p = 1.2e-13) and with hepatitis C (OR = 1.20, p<2e-16). For liver transplantation, there was a significant interaction between genotype and hepatitis C (ZZ: interaction OR = 1.23, p = 4.7e-4; MZ: interaction OR = 1.11, p = 6.9e-13). Sequencing uncovered a second, rare, pathogenic SERPINA1 variant in six of 133 individuals with liver transplants and without hepatitis C. Liver transplantation was more common in individuals with AATD risk alleles (including heterozygotes), and AATD and hepatitis C demonstrated evidence of a gene-environment interaction in relation to liver transplantation. The current AATD screening strategy may miss diagnoses whereas SERPINA1 sequencing may increase diagnostic yield for AATD, stratify risk for liver disease, and inform clinical management for individuals with AATD risk alleles and liver disease risk factors.
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Affiliation(s)
- Bryce A. Schuler
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Janey Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Joshua C. Denny
- All of Us Research Program, National Institutes of Health, Bethesda, Maryland, United States of America
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
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Grabowska ME, Van Driest SL, Robinson JR, Patrick AE, Guardo C, Gangireddy S, Ong H, Feng Q, Carroll R, Kannankeril PJ, Wei WQ. Developing and Evaluating Pediatric Phecodes (Peds-Phecodes) for High-Throughput Phenotyping Using Electronic Health Records. medRxiv 2023:2023.08.22.23294435. [PMID: 37662278 PMCID: PMC10473796 DOI: 10.1101/2023.08.22.23294435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Objective Pediatric patients have different diseases and outcomes than adults; however, existing phecodes do not capture the distinctive pediatric spectrum of disease. We aim to develop specialized pediatric phecodes (Peds-Phecodes) to enable efficient, large-scale phenotypic analyses of pediatric patients. Materials and Methods We adopted a hybrid data- and knowledge-driven approach leveraging electronic health records (EHRs) and genetic data from Vanderbilt University Medical Center to modify the most recent version of phecodes to better capture pediatric phenotypes. First, we compared the prevalence of patient diagnoses in pediatric and adult populations to identify disease phenotypes differentially affecting children and adults. We then used clinical domain knowledge to remove phecodes representing phenotypes unlikely to affect pediatric patients and create new phecodes for phenotypes relevant to the pediatric population. We further compared phenome-wide association study (PheWAS) outcomes replicating known pediatric genotype-phenotype associations between Peds-Phecodes and phecodes. Results The Peds-Phecodes aggregate 15,533 ICD-9-CM codes and 82,949 ICD-10-CM codes into 2,051 distinct phecodes. Peds-Phecodes replicated more known pediatric genotype-phenotype associations than phecodes (248 versus 192 out of 687 SNPs, p<0.001). Discussion We introduce Peds-Phecodes, a high-throughput EHR phenotyping tool tailored for use in pediatric populations. We successfully validated the Peds-Phecodes using genetic replication studies. Our findings also reveal the potential use of Peds-Phecodes in detecting novel genotype-phenotype associations for pediatric conditions. We expect that Peds-Phecodes will facilitate large-scale phenomic and genomic analyses in pediatric populations. Conclusion Peds-Phecodes capture higher-quality pediatric phenotypes and deliver superior PheWAS outcomes compared to phecodes.
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9
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Mosley JD, Shelley JP, Dickson AL, Zanussi J, Daniel LL, Zheng NS, Bastarache L, Wei WQ, Shi M, Jarvik GP, Rosenthal EA, Khan A, Sherafati A, Kullo IJ, Walunas TL, Glessner J, Hakonarson H, Cox NJ, Roden DM, Frangakis SG, Vanderwerff B, Stein CM, Van Driest SL, Borinstein SC, Shu XO, Zawistowski M, Chung CP, Kawai VK. Clinical consequences of a polygenic predisposition to benign lower white blood cell counts: Consequences of benign WBC count genetics. medRxiv 2023:2023.08.20.23294331. [PMID: 37662324 PMCID: PMC10473820 DOI: 10.1101/2023.08.20.23294331] [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] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Polygenic variation unrelated to disease contributes to interindividual variation in baseline white blood cell (WBC) counts, but its clinical significance is undefined. We investigated the clinical consequences of a genetic predisposition toward lower WBC counts among 89,559 biobank participants from tertiary care centers using a polygenic score for WBC count (PGSWBC) comprising single nucleotide polymorphisms not associated with disease. A predisposition to lower WBC counts was associated with a decreased risk of identifying pathology on a bone marrow biopsy performed for a low WBC count (odds-ratio=0.55 per standard deviation increase in PGSWBC [95%CI, 0.30 - 0.94], p=0.04), an increased risk of leukopenia (a low WBC count) when treated with a chemotherapeutic (n=1,724, hazard ratio [HR]=0.78 [0.69 - 0.88], p=4.0×10-5) or immunosuppressant (n=354, HR=0.61 [0.38 - 0.99], p=0.04). A predisposition to benign lower WBC counts was associated with an increased risk of discontinuing azathioprine treatment (n=1,466, HR=0.62 [0.44 - 0.87], p=0.006). Collectively, these findings suggest that a WBC count polygenic score identifies individuals who are susceptible to escalations or alterations in clinical care that may be harmful or of little benefit.
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Affiliation(s)
- Jonathan D. Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John P. Shelley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alyson L. Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jacy Zanussi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L. Daniel
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Neil S. Zheng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gail P. Jarvik
- Department of Genome Sciences, University of Washington Medical Center, Seattle WA, USA
- Department of Medicine (Medical Genetics), University of Washington Medical Center, Seattle WA, USA
| | - Elisabeth A. Rosenthal
- Department of Medicine (Medical Genetics), University of Washington Medical Center, Seattle WA, USA
| | - Atlas Khan
- Division of Nephrology, Dept of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY
| | - Alborz Sherafati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester MN USA
| | - Iftikhar J. Kullo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester MN USA
| | - Theresa L. Walunas
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joe Glessner
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy J. Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dan M. Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan G. Frangakis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Brett Vanderwerff
- Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, USA
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L. Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott C. Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiao-Ou Shu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Matthew Zawistowski
- Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, USA
| | - Cecilia P. Chung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vivian K. Kawai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Chevalier R, Attard T, Van Driest SL, Shakhnovich V. A fresh look at proton pump inhibitor (PPI)-associated adverse events through a CYP2C19 pharmacogenetic lens. Expert Opin Drug Metab Toxicol 2023; 19:53-56. [PMID: 36919492 DOI: 10.1080/17425255.2023.2190883] [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: 03/16/2023]
Affiliation(s)
- Rachel Chevalier
- University of Missouri School of Medicine, Kansas, MO, USA
- Children's Mercy Kansas City, Division of Gastroenterology, Hepatology and Nutrition, Kansas City, MO, USA
| | - Thomas Attard
- University of Missouri School of Medicine, Kansas, MO, USA
- Children's Mercy Kansas City, Division of Gastroenterology, Hepatology and Nutrition, Kansas City, MO, USA
| | - Sara L Van Driest
- Department of Pediatrics, Center for Pediatric Precision Medicine, Nashville, TN, USA
| | - Valentina Shakhnovich
- University of Missouri School of Medicine, Kansas, MO, USA
- Children's Mercy Kansas City, Division of Gastroenterology, Hepatology and Nutrition, Kansas City, MO, USA
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11
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Jasper EA, Holley SE, Jones SH, Liu M, Israel T, Van Driest SL, Velez Edwards DR. Tutorial: Using Community Engagement Studios to Enhance Pharmacogenetic Study Design for Maximizing Enrollment of Diverse Children and Pregnant People. Clin Pharmacol Ther 2023; 113:607-614. [PMID: 36366911 PMCID: PMC9957793 DOI: 10.1002/cpt.2792] [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: 08/31/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022]
Abstract
Most pharmacogenetic research is conducted in adult, non-pregnant populations of European ancestry. Study of more diverse and special populations is necessary to validate findings and improve health equity. However, there are significant barriers to recruitment of diverse populations for genetic studies, such as mistrust of researchers due to a history of unethical research and ongoing social inequities. Engaging communities and understanding community members' perspectives may help to overcome these barriers and improve research quality. Here, we highlight one method for engaging communities, the Community Engagement Studio (CES), a consultative session that allows researchers to obtain guidance and feedback based on community members' lived experiences. We also provide an example of its use in pharmacogenetic studies. In designing a survey study of knowledge and attitudes around pharmacogenetic testing among children with chronic conditions and pregnant individuals, we sought input from diverse community stakeholders through CESs at Vanderbilt University Medical Center. We participated in two CESs with community stakeholders representing study target populations. Our goals were to learn specific concerns about pharmacogenetic testing and preferred recruitment strategies for these communities. Concerns were expressed about how genetic information would be used beyond the immediate study. Participants emphasized the importance of clarity and transparency in communication to overcome participation hesitancy and mistrust of the study team. Recruitment strategy recommendations ranged from informal notices posted in healthcare settings to provider referrals. The CES enabled us to modify our recruitment methods and research materials to better communicate with populations currently under-represented in pharmacogenetics research.
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Affiliation(s)
- Elizabeth A Jasper
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sabrina E Holley
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah H Jones
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tiffany Israel
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Digna R Velez Edwards
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Genetics Institute, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Bagheri M, Chung CP, Dickson AL, Van Driest SL, Borinstein SC, Mosley JD. White blood cell ranges and frequency of neutropenia by Duffy genotype status. Blood Adv 2023; 7:406-409. [PMID: 35895516 PMCID: PMC9979714 DOI: 10.1182/bloodadvances.2022007680] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Minoo Bagheri
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Cecilia P. Chung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alyson L. Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L. Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Scott C. Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D. Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
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13
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Liu M, Rossow KM, Maxwell-Horn AC, Saucier LA, Van Driest SL. Pediatric considerations for pharmacogenetic selective serotonin reuptake inhibitors clinical decision support. Pharmacotherapy 2022. [PMID: 36524442 DOI: 10.1002/phar.2751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/27/2022] [Accepted: 10/30/2022] [Indexed: 12/23/2022]
Abstract
Pharmacogenetic testing for psychiatry is growing at a rapid pace, with multiple sites utilizing results to help clinical decision-making. Genotype-guided dosing and drug selection have been implemented at several sites, including Vanderbilt University Medical Center, where clinical decision support (CDS) based on pharmacogenetic results went live for selective serotonin reuptake inhibitors in 2020 for both adult and pediatric patients. Effective and appropriate implementation of CYP2D6- and CYP2C19-guided CDS for the pediatric population requires consideration of the evidence for the pharmacogenetic associations, medication indications, and appropriate alternative therapies to be used when a pharmacogenetic contraindication is identified. In this article, we review these pediatric pharmacogenetic considerations for selective serotonin reuptake inhibitor CDS. We include a case study, the current literature supporting clinical recommendations, considerations when designing pediatric CDS, future implications, and examples of sertraline, (es)citalopram, paroxetine, and fluvoxamine alerts.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katelyn M Rossow
- Developmental-Behavioral Pediatrics, Norton Children's Development Center, Louisville, Kentucky, USA
| | - Angela C Maxwell-Horn
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh Ann Saucier
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Kikano S, Breeyear J, Aka I, Edwards TL, Van Driest SL, Kannankeril PJ. Association between nitric oxide synthase 3 genetic variant and acute kidney injury following pediatric cardiac surgery. Am Heart J 2022; 254:57-65. [PMID: 35988586 PMCID: PMC10925835 DOI: 10.1016/j.ahj.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/02/2022] [Revised: 07/10/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) complicates 30% to 50% of cardiac surgeries in pediatric patients. Genetic variants that affect renal blood flow and inflammation have been associated with AKI after cardiac surgery in diverse populations of adults but have not been studied in children. The objective of this study is to test the hypothesis that common candidate genetic variants are associated with AKI following pediatric cardiac surgery. METHODS This is a retrospective cohort study at a single tertiary referral children's hospital of 2,062 individual patients undergoing surgery for congenital heart disease from September 2007 to July 2020. Pre-specified variants in candidate genes (AGTR1, APOE, IL6, NOS3, and TNF) were chosen. AKI was defined using Kidney Disease: Improving Global Outcomes serum creatinine criteria in the first week following surgery. Outcomes were analyzed by univariate and multivariable analysis of demographic, clinical, and genetic factors. RESULTS The study population had median age of 6 (interquartile range [IQR], 1-53) months, 759 (37%) of whom met criteria for postoperative AKI. In unadjusted analyses of each genetic variant, only NOS3 (rs2070744) was associated with lower risk for AKI (OR 0.75, 95% CI 0.62-0.9, P = .002). In logistic regression analyses adjusting for body surface area, previously identified genetic syndrome, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) score, cardiopulmonary bypass time, and nephrotoxic medication exposure, the NOS3 variant remained protective against AKI (OR 0.7, 95% CI 0.58-0.85, P<.001). CONCLUSIONS A common variant in NOS3 is associated with decreased incidence of AKI in children undergoing cardiac surgery. Further analysis of the genetic contributions to postoperative AKI may help identify individual risk in the pediatric population.
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Affiliation(s)
- Sandra Kikano
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN.
| | - Joseph Breeyear
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ida Aka
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Todd L Edwards
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Prince J Kannankeril
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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15
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Black K, Brenn BR, Gaedigk A, Wanderer JP, Van Driest SL. Pediatric CYP2D6 metabolizer status and post-tonsillectomy nausea and vomiting after ondansetron. Clin Transl Sci 2022; 16:269-278. [PMID: 36350309 PMCID: PMC9926081 DOI: 10.1111/cts.13447] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
The goal of this study was to determine whether CYP2D6 metabolizer status within the ondansetron-treated pediatric tonsillectomy population is associated with risk of postoperative nausea and vomiting (PONV) in the post-anesthesia care unit. We conducted a retrospective cohort study of pediatric patients (<18 years) who underwent tonsillectomy and received ondansetron on the day of the procedure. Data were obtained from BioVU, an institutional biobank that links DNA to de-identified electronic health record data. Subjects were tested for 10 CYP2D6 allelic variants and copy number variation, and genotype data translated into CYP2D6 metabolizer status. The cohort included 652 individuals, 105 (16.1%) of whom had PONV. Rates of PONV were similar across groups: ultrarapid metabolizers (UMs), 1 of 9 (11.1%); normal metabolizers (NMs), 64 of 354 (18.1%); intermediate metabolizers (IMs), 33 of 234 (14.1%); poor metabolizers (PMs), 6 of 39 (15.4%); and ambiguous phenotypes, 1 of 16 (6.3%). In multivariable analysis adjusted for age, sex, and time under anesthesia, CYP2D6 metabolizer status was not associated with PONV, with an odds ratio of 1.37 (95% confidence interval 0.9, 2.1) when comparing PM/IM versus NM/UM. In this large pediatric population, no significant differences were detected for PONV based on CYP2D6 metabolizer status. Further investigation is needed to determine mechanisms for ondansetron inefficacy in children.
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Affiliation(s)
- Katherine Black
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and NutritionVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - B. Randall Brenn
- Division of Pediatric AnesthesiaShriner's Hospitals for Children‐PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City and Department of PediatricsUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Jonathan P. Wanderer
- Departments of Anesthesiology and Biomedical InformaticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sara L. Van Driest
- Departments of Pediatrics and Medicine, and the Center for Pediatric Precision MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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16
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Leppig KA, Rahm AK, Appelbaum P, Aufox S, Bland ST, Buchanan A, Christensen KD, Chung WK, Clayton EW, Crosslin D, Denny J, DeVange S, Gordon A, Green RC, Hakonarson H, Harr MH, Henrikson N, Hoell C, Holm IA, Kullo IJ, Jarvik GP, Lammers PE, Larson EB, Lindor NM, Marasa M, Myers MF, Perez E, Peterson JF, Pratap S, Prows CA, Ralston JD, Rasouly HM, Roden DM, Sharp RR, Singh R, Shaibi G, Smith ME, Sturm A, Thiese HA, Van Driest SL, Williams J, Williams MS, Wynn J, Blout Zawatsky CL, Wiesner GL. The Reckoning: The Return of Genomic Results to 1444 Participants Across the eMERGE3 Network. Obstet Gynecol Surv 2022. [DOI: 10.1097/01.ogx.0000899476.28549.ef] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Cavallari LH, Cicali E, Wiisanen K, Fillingim RB, Chakraborty H, Myers RA, Blake KV, Asiyanbola B, Baye JF, Bronson WH, Cook KJ, Elwood EN, Gray CF, Gong Y, Hines L, Kannry J, Kucher N, Lynch S, Nguyen KA, Obeng AO, Pratt VM, Prieto HA, Ramos M, Sadeghpour A, Singh R, Rosenman M, Starostik P, Thomas CD, Tillman E, Dexter PR, Horowitz CR, Orlando LA, Peterson JF, Skaar TC, Van Driest SL, Volpi S, Voora D, Parvataneni HK, Johnson JA. Implementing a pragmatic clinical trial to tailor opioids for acute pain on behalf of the IGNITE ADOPT PGx investigators. Clin Transl Sci 2022; 15:2479-2492. [PMID: 35899435 PMCID: PMC9579394 DOI: 10.1111/cts.13376] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/09/2022] [Accepted: 07/13/2022] [Indexed: 01/25/2023] Open
Abstract
Opioid prescribing for postoperative pain management is challenging because of inter-patient variability in opioid response and concern about opioid addiction. Tramadol, hydrocodone, and codeine depend on the cytochrome P450 2D6 (CYP2D6) enzyme for formation of highly potent metabolites. Individuals with reduced or absent CYP2D6 activity (i.e., intermediate metabolizers [IMs] or poor metabolizers [PMs], respectively) have lower concentrations of potent opioid metabolites and potentially inadequate pain control. The primary objective of this prospective, multicenter, randomized pragmatic trial is to determine the effect of postoperative CYP2D6-guided opioid prescribing on pain control and opioid usage. Up to 2020 participants, age ≥8 years, scheduled to undergo a surgical procedure will be enrolled and randomized to immediate pharmacogenetic testing with clinical decision support (CDS) for CYP2D6 phenotype-guided postoperative pain management (intervention arm) or delayed testing without CDS (control arm). CDS is provided through medical record alerts and/or a pharmacist consult note. For IMs and PM in the intervention arm, CDS includes recommendations to avoid hydrocodone, tramadol, and codeine. Patient-reported pain-related outcomes are collected 10 days and 1, 3, and 6 months after surgery. The primary outcome, a composite of pain intensity and opioid usage at 10 days postsurgery, will be compared in the subgroup of IMs and PMs in the intervention (n = 152) versus the control (n = 152) arm. Secondary end points include prescription pain medication misuse scores and opioid persistence at 6 months. This trial will provide data on the clinical utility of CYP2D6 phenotype-guided opioid selection for improving postoperative pain control and reducing opioid-related risks.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
| | - Emily Cicali
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
| | - Kristin Wiisanen
- Department of Community Dentistry and Behavioral Science, College of DentistryUniversity of FloridaGainesvilleFloridaUSA
| | - Roger B. Fillingim
- Department of Community Dentistry and Behavioral Science, College of DentistryUniversity of FloridaGainesvilleFloridaUSA
| | | | - Rachel A. Myers
- Duke Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Kathryn V. Blake
- Center for Pharmacogenomics and Translational ResearchNemours Children's HealthJacksonvilleFloridaUSA
| | | | | | - Wesley H. Bronson
- Department of Orthopaedic SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Kelsey J. Cook
- Center for Pharmacogenomics and Translational ResearchNemours Children's HealthJacksonvilleFloridaUSA,Department of Pharmacotherapy and Translational Research, College of PharmacyUniversity of FloridaJacksonvilleFloridaUSA
| | - Erica N. Elwood
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
| | - Chancellor F. Gray
- Department of Orthopaedic Surgery, College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
| | - Lindsay Hines
- Brain and Spine CenterSanford HealthFargoNorth DakotaUSA
| | - Joseph Kannry
- Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Natalie Kucher
- Division of Genomic MedicineNational Human Genome Research Institute, NIHBethesdaMarylandUSA
| | - Sheryl Lynch
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Khoa A. Nguyen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
| | - Aniwaa Owusu Obeng
- Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Victoria M. Pratt
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA,Optum GenomicsMinnetonkaMNUSA
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery, College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Michelle Ramos
- Department of Population Health Science and Policy and Institute for Health Equity ResearchIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Azita Sadeghpour
- Duke Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNorth CarolinaUSA
| | | | - Marc Rosenman
- School of MedicineIndiana UniversityIndianapolisIndianaUSA,Ann & Robert H. Lurie Children's Hospital of Chicago and Institute of Public Health, Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Petr Starostik
- Department of Pathology, College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
| | - Emma Tillman
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Paul R. Dexter
- School of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Carol R. Horowitz
- Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA,Department of Population Health Science and Policy and Institute for Health Equity ResearchIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Lori A. Orlando
- Duke Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Josh F. Peterson
- Departments of Biomedical Informatics and MedicineVanderbilt University, Medical CenterNashvilleTennesseeUSA
| | - Todd C. Skaar
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Sara L. Van Driest
- Departments of Pediatrics and MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Simona Volpi
- Division of Genomic MedicineNational Human Genome Research Institute, NIHBethesdaMarylandUSA
| | - Deepak Voora
- Duke Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Hari K. Parvataneni
- Department of Orthopaedic Surgery, College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFloridaUSA
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18
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Challa AP, Niu X, Garrison EA, Van Driest SL, Bastarache LM, Lippmann ES, Lavieri RR, Goldstein JA, Aronoff DM. Medication history-wide association studies for pharmacovigilance of pregnant patients. Commun Med 2022; 2:115. [PMID: 36124058 PMCID: PMC9481638 DOI: 10.1038/s43856-022-00181-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Systematic exclusion of pregnant people from interventional clinical trials has created a public health emergency for millions of patients through a dearth of robust safety data for common drugs.
Methods
We harnessed an enterprise collection of 2.8 M electronic health records (EHRs) from routine care, leveraging data linkages between mothers and their babies to detect drug safety signals in this population at full scale. Our mixed-methods signal detection approach stimulates new hypotheses for post-marketing surveillance agnostically of both drugs and diseases—by identifying 1,054 drugs historically prescribed to pregnant patients; developing a quantitative, medication history-wide association study; and integrating a qualitative evidence synthesis platform using expert clinician review for integration of biomedical specificity—to test the effects of maternal exposure to diverse drugs on the incidence of neurodevelopmental defects in their children.
Results
We replicated known teratogenic risks and existing knowledge on drug structure-related teratogenicity; we also highlight 5 common drug classes for which we believe this work warrants updated assessment of their safety.
Conclusion
Here, we present roots of an agile framework to guide enhanced medication regulations, as well as the ontological and analytical limitations that currently restrict the integration of real-world data into drug safety management during pregnancy. This research is not a replacement for inclusion of pregnant people in prospective clinical studies, but it presents a tractable team science approach to evaluating the utility of EHRs for new regulatory review programs—towards improving the delicate equipoise of accuracy and ethics in assessing drug safety in pregnancy.
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19
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Dickson AL, Daniel LL, Jackson E, Zanussi J, Yang W, Plummer WD, Dupont WD, Wei WQ, Nepal P, Hung AM, Cox NJ, Van Driest SL, Feng Q, Yang JJ, Stein CM, Mosley JD, Chung CP. Race, Genotype, and Azathioprine Discontinuation : A Cohort Study. Ann Intern Med 2022; 175:1092-1099. [PMID: 35724382 PMCID: PMC9378477 DOI: 10.7326/m21-4675] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Thiopurines are an important class of immunosuppressants despite their risk for hematopoietic toxicity and narrow therapeutic indices. Benign neutropenia related to an ACKR1 variant (rs2814778-CC) is common among persons of African ancestries. OBJECTIVE To test whether rs2814778-CC was associated with azathioprine discontinuation attributed to hematopoietic toxicity and lower thiopurine dosing. DESIGN Retrospective cohort study. SETTING Two tertiary care centers. PATIENTS Thiopurine users with White or Black race. MEASUREMENTS Azathioprine discontinuation attributed to hematopoietic toxicity. Secondary outcomes included weight-adjusted final dose, leukocyte count, and change in leukocyte count. RESULTS The rate of azathioprine discontinuation attributed to hematopoietic toxicity was 3.92 per 100 person-years among patients with the CC genotype (n = 101) and 1.34 per 100 person-years among those with the TT or TC genotype (n = 1365) (hazard ratio [HR] from competing-risk model, 2.92 [95% CI, 1.57 to 5.41]). The risk remained significant after adjustment for race (HR, 2.61 [CI, 1.01 to 6.71]). The risk associated with race alone (HR, 2.13 [CI, 1.21 to 3.75]) was abrogated by adjustment for genotype (HR, 1.13 [CI, 0.48 to 2.69]). Lower last leukocyte count and lower dosing were significant among patients with the CC genotype. Lower dosing was validated in an external cohort of 94 children of African ancestries prescribed the thiopurine 6-mercaptopurine (6-MP) for acute lymphoblastic leukemia. The CC genotype was independently associated with lower 6-MP dose intensity relative to the target daily dose of 75 mg/m2 (median, 0.83 [IQR, 0.70 to 0.94] for the CC genotype vs. 0.94 [IQR, 0.72 to 1.13] for the TT or TC genotype; P = 0.013). LIMITATIONS Unmeasured confounding; data limited to tertiary centers. CONCLUSION Patients with the CC genotype had higher risk for azathioprine discontinuation attributed to hematopoietic toxicity and lower thiopurine doses. Genotype was associated with those risks, even after adjustment for race. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Alyson L Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Laura L Daniel
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Elise Jackson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Jacy Zanussi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Wenjian Yang
- Pharmacy and Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee (W.Y., J.J.Y.)
| | - W Dale Plummer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee (W.D.P., W.D.D.)
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee (W.D.P., W.D.D.)
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee (W.W.)
| | - Puran Nepal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Nancy J Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Sara L Van Driest
- Departments of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee (S.L.V.)
| | - QiPing Feng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Jun J Yang
- Pharmacy and Pharmaceutical Sciences Department, St. Jude Children's Research Hospital, Memphis, Tennessee (W.Y., J.J.Y.)
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
| | - Jonathan D Mosley
- Departments of Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee (J.D.M.)
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (A.L.D., L.L.D., E.J., J.Z., P.N., A.M.H., N.J.C., Q.F., C.M.S., C.P.C.)
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20
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Borinstein SC, Agamasu D, Schildcrout JS, Bastarache L, Bagheri M, Davis LK, Roden DM, Michael Stein C, Van Driest SL, Mosley JD. Frequency of benign neutropenia among Black versus White individuals undergoing a bone marrow assessment. J Cell Mol Med 2022; 26:3628-3635. [PMID: 35642720 PMCID: PMC9258701 DOI: 10.1111/jcmm.17346] [Citation(s) in RCA: 2] [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: 01/12/2022] [Revised: 03/14/2022] [Accepted: 04/05/2022] [Indexed: 01/01/2023] Open
Abstract
Healthy individuals in the United States identified as having Black race have lower neutrophil counts, on average, than individuals identified as having White race, which could result in more negative diagnostic evaluations for neutropenia. To test this hypothesis, the proportion of evaluations where the final diagnosis was clinically insignificant neutropenia for Black and White individuals who underwent an evaluation by a haematologist that included a bone marrow (BM) biopsy to investigate neutropenia was assessed. 172 individuals without prior haematological diagnoses who underwent a haematological evaluation to investigate neutropenia. Individuals diagnosed with clinically insignificant neutropenia between Black and White individuals were compared using a propensity-score-adjusted logistic regression. Of 172 individuals, 42 (24%) were classified as Black race, 86 (50%) were males, and the 79 (46%) were over 18 years old. A BM biopsy did not identify pathology in 95% (40 of 42) of Black individuals and 68% (89 of 130) of White Individuals. Black individuals (25 of 42 [60%]) received a final diagnosis of clinically insignificant neutropenia, compared to White individuals (12 of 130 [9%]) (adjusted odds ratio =7.9, 95% CI: 3.1 - 21.1). We conclude that black individuals were more likely to receive a diagnosis of clinically insignificant neutropenia after haematological assessment.
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Affiliation(s)
- Scott C Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jonathan S Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Minoo Bagheri
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lea K Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Mosley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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21
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Liu M, Shaver CM, Birdwell KA, Heeney SA, Shaffer CM, Van Driest SL. Composite CYP3A phenotypes influence tacrolimus dose-adjusted concentration in lung transplant recipients. Pharmacogenet Genomics 2022; 32:209-217. [PMID: 35389944 PMCID: PMC9177686 DOI: 10.1097/fpc.0000000000000472] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Interpatient variability in tacrolimus pharmacokinetics is attributed to metabolism by cytochrome P-450 3A4/5 isoenzymes (encoded by CYP3A4 and CYP3A5). Guidelines for adjusting tacrolimus based on CYP3A5 test results are published; however, CYP3A4 variants also contribute to the variability in tacrolimus pharmacokinetics. The effects of composite phenotypes incorporating CYP3A5 and CYP3A4 increased (*1G, *1B) and decreased (*22) function variants have not been evaluated. The objective of this study is to investigate the impact of both increased and decreased function CYP3A variants on weight and dose-adjusted tacrolimus concentration (C0/D). METHODS We performed a single-center retrospective cohort study of lung transplant recipients to evaluate the median tacrolimus C0/D by composite CYP3A phenotype groups during the index transplant hospitalization. CYP3A4 and CYP3A5 alleles were used to classify patients into four CYP3A groups from least to most CYP3A activity. Exploratory analyses of ABCB1 and additional candidate genes were also assessed. RESULTS Of the 92 included individuals, most (58) were CYP3A Group 2. The median tacrolimus C0/D differed significantly between CYP3A groups (P = 0.0001). CYP3A Group 2 median tacrolimus C0/D was 190.5 (interquartile range: 147.6-267.5) (ng/ml)/(mg/kg/d) and significantly higher than Group 4 [107.9 (90.4-116.1), P = 0.0001)]. Group 2 median tacrolimus C0/D did not significantly differ from Group 1 and Group 3 [373.5 (149.2-490.3) and 81.4 (62.6-184.1), respectively]. No significant differences in tacrolimus C0/D were found for the ABCB1 diplotypes. CONCLUSION These data indicate that a composite CYP3A phenotype incorporating both increase and decrease variant information from CYP3A4 in addition to CYP3A5 may significantly influence tacrolimus C0/D during the early postoperative period.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ciara M. Shaver
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A. Birdwell
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie A. Heeney
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christian M. Shaffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara L. Van Driest
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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22
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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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23
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Sunthankar SD, Kannankeril PJ, Gaedigk A, Radbill AE, Fish FA, Van Driest SL. Influence of CYP2D6 Genetic Variation on Adverse Events with Propafenone in the Pediatric and Young Adult Population. Clin Transl Sci 2022; 15:1787-1795. [PMID: 35514162 PMCID: PMC9283732 DOI: 10.1111/cts.13296] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/12/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Propafenone is an antiarrhythmic drug metabolized primarily by cytochrome P450 2D6 (CYP2D6). In adults, propafenone adverse events (AEs) are associated with CYP2D6 poor metabolizer status; however, pediatric data are lacking. Subjects were tested for 10 CYP2D6 allelic variants and copy number status, and activity scores assigned to each genotype. Seventy‐six individuals (median 0.3 [range 0–26] years old) were included. Propafenone AEs occurred in 29 (38%); 14 (18%) required drug discontinuation due to AE. The most common AEs were QRS (n = 10) and QTc (n = 6) prolongation. Those with AEs were older at the time of propafenone initiation (1.58 [0.13–9.92] vs. 0.20 [0.08–2.01] years old; p = 0.042). CYP2D6 activity scores were not associated with presence of an AE (odds ratio [OR] 0.48 [0.22–1.03]; p = 0.055) but with the total number of AE (β1 = −0.31 [−0.60, −0.03]; p = 0.029), systemic AEs (OR 0.33 [0.13–0.88]; p = 0.022), and drug discontinuation for systemic AEs (OR 0.28 [0.09–0.83]; p = 0.017). Awareness of CYP2D6 activity score and patient age may aid in determining an individual's risk for an AE with propafenone administration.
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Affiliation(s)
- Sudeep D Sunthankar
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prince J Kannankeril
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Andrew E Radbill
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frank A Fish
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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24
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Meester JAN, Peeters S, Van Den Heuvel L, Vandeweyer G, Fransen E, Cappella E, Dietz HC, Forbus G, Gelb BD, Goldmuntz E, Hoskoppal A, Landstrom AP, Lee T, Mital S, Morris S, Olson AK, Renard M, Roden DM, Singh MN, Selamet Tierney ES, Tretter JT, Van Driest SL, Willing M, Verstraeten A, Van Laer L, Lacro RV, Loeys BL. Molecular characterization and investigation of the role of genetic variation in phenotypic variability and response to treatment in a large pediatric Marfan syndrome cohort. Genet Med 2022; 24:1045-1053. [PMID: 35058154 PMCID: PMC9680912 DOI: 10.1016/j.gim.2021.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE In a large cohort of 373 pediatric patients with Marfan syndrome (MFS) with a severe cardiovascular phenotype, we explored the proportion of patients with MFS with a pathogenic FBN1 variant and analyzed whether the type/location of FBN1 variants was associated with specific clinical characteristics and response to treatment. Patients were recruited on the basis of the following criteria: aortic root z-score > 3, age 6 months to 25 years, no prior or planned surgery, and aortic root diameter < 5 cm. METHODS Targeted resequencing and deletion/duplication testing of FBN1 and related genes were performed. RESULTS We identified (likely) pathogenic FBN1 variants in 91% of patients. Ectopia lentis was more frequent in patients with dominant-negative (DN) variants (61%) than in those with haploinsufficient variants (27%). For DN FBN1 variants, the prevalence of ectopia lentis was highest in the N-terminal region (84%) and lowest in the C-terminal region (17%). The association with a more severe cardiovascular phenotype was not restricted to DN variants in the neonatal FBN1 region (exon 25-33) but was also seen in the variants in exons 26 to 49. No difference in the therapeutic response was detected between genotypes. CONCLUSION Important novel genotype-phenotype associations involving both cardiovascular and extra-cardiovascular manifestations were identified, and existing ones were confirmed. These findings have implications for prognostic counseling of families with MFS.
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Affiliation(s)
- Josephina A N Meester
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Silke Peeters
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Lotte Van Den Heuvel
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Geert Vandeweyer
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Erik Fransen
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; StatUa Center for Statistics, University of Antwerp, Antwerp, Belgium
| | | | - Harry C Dietz
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD; Howard Hughes Medical Institute, Baltimore, MD
| | - Geoffrey Forbus
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
| | - Bruce D Gelb
- Departments of Pediatrics and Genetics & Genomic Sciences, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arvind Hoskoppal
- Departments of Pediatrics and Internal Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, UT
| | - Andrew P Landstrom
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Teresa Lee
- Children's Hospital of New York, New York City, NY
| | - Seema Mital
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shaine Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Aaron K Olson
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Marjolijn Renard
- Center for Medical Genetics Ghent, Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael N Singh
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Marcia Willing
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Aline Verstraeten
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Lut Van Laer
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Ronald V Lacro
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Bart L Loeys
- Center of Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.
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25
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Breeyear JH, Keaton JM, Torstenson ES, Smith AH, Klarin D, Damrauer SM, Natarajan P, Van Driest SL, Weiner JG, Kannankeril PJ, Edwards TL. Diastolic Blood Pressure Alleles Improve Congenital Heart Defect Repair Outcomes. Circ Res 2022; 130:1030-1037. [PMID: 35199555 PMCID: PMC9811841 DOI: 10.1161/circresaha.121.319842] [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: 01/07/2023]
Abstract
BACKGROUND Congenital heart defects (CHDs) affect 40 000 US births per year, half of which require surgical intervention. Individual differences in surgical outcomes including mortality and complications are not well understood but may be due to genetic variability. We hypothesized that polygenic risk scores (PRSs) for blood pressure in adults are associated with treatments and postsurgical outcomes in children with CHD, as CHD survivors are at higher risk of negative cardiometabolic disease. METHODS We used imputed genotype data from pediatric participants requiring surgery for CHD (median age at surgery, 201 days; nmax=2498). Base data for the systolic and diastolic blood pressure PRSs (nmax=760 226) came from published genome-wide association study. The blood pressure PRSs were tested for association with postsurgical outcomes. All effects presented are per SD increase in PRS and adjusted for age, sex, body mass index, surgical complexity score, and first 10 principal components of ancestry. RESULTS A higher diastolic blood pressure PRS was associated with decreased in-hospital mortality risk (odds ratio, 0.57 [0.39-0.82]; P=0.0022). Additional analyses suggest an interaction between diastolic blood pressure PRS and vasopressor dose. Those with a diastolic blood pressure PRS 1 SD above the mean, receiving a vasopressor dose in the top tertile, were estimated to have 52% (32%-66%) lower risk of in-hospital mortality compared with those with a vasopressor dose in the bottom tertile. CONCLUSIONS These results suggest a genetically determined postsurgical survival advantage for CHD patients with blood pressure increasing alleles. Further study may reveal novel mechanisms contributing to postoperative morbidity and mortality, and this approach may assist in early identification of children at risk for adverse postoperative outcomes.
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Affiliation(s)
- Joseph H. Breeyear
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M. Keaton
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Eric S. Torstenson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew H. Smith
- Division of Cardiac Critical Care Medicine, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida
| | - Derek Klarin
- Veterans Affairs Boston Healthcare System, Boston, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA; Division of Vascular Surgery and Endovascular Therapy, University of Florida School of Medicine, Gainesville, FL, USA
| | - Scott M. Damrauer
- Corporal Michael Crescenz VA Medical Center, Philadelphia, PA; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pradeep Natarajan
- Veterans Affairs Boston Healthcare System, Boston, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA; Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara L. Van Driest
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey G. Weiner
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Prince J. Kannankeril
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd L. Edwards
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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26
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Glazer AM, Davogustto G, Shaffer CM, Vanoye CG, Desai RR, Farber-Eger EH, Dikilitas O, Shang N, Pacheco JA, Yang T, Muhammad A, Mosley JD, Van Driest SL, Wells QS, Shaffer LL, Kalash OR, Wada Y, Bland S, Yoneda ZT, Mitchell DW, Kroncke BM, Kullo IJ, Jarvik GP, Gordon AS, Larson EB, Manolio TA, Mirshahi T, Luo JZ, Schaid D, Namjou B, Alsaied T, Singh R, Singhal A, Liu C, Weng C, Hripcsak G, Ralston JD, McNally EM, Chung WK, Carrell DS, Leppig KA, Hakonarson H, Sleiman P, Sohn S, Glessner J, Denny J, Wei WQ, George AL, Shoemaker MB, Roden DM. Arrhythmia Variant Associations and Reclassifications in the eMERGE-III Sequencing Study. Circulation 2022; 145:877-891. [PMID: 34930020 PMCID: PMC8940719 DOI: 10.1161/circulationaha.121.055562] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sequencing Mendelian arrhythmia genes in individuals without an indication for arrhythmia genetic testing can identify carriers of pathogenic or likely pathogenic (P/LP) variants. However, the extent to which these variants are associated with clinically meaningful phenotypes before or after return of variant results is unclear. In addition, the majority of discovered variants are currently classified as variants of uncertain significance, limiting clinical actionability. METHODS The eMERGE-III study (Electronic Medical Records and Genomics Phase III) is a multicenter prospective cohort that included 21 846 participants without previous indication for cardiac genetic testing. Participants were sequenced for 109 Mendelian disease genes, including 10 linked to arrhythmia syndromes. Variant carriers were assessed with electronic health record-derived phenotypes and follow-up clinical examination. Selected variants of uncertain significance (n=50) were characterized in vitro with automated electrophysiology experiments in HEK293 cells. RESULTS As previously reported, 3.0% of participants had P/LP variants in the 109 genes. Herein, we report 120 participants (0.6%) with P/LP arrhythmia variants. Compared with noncarriers, arrhythmia P/LP carriers had a significantly higher burden of arrhythmia phenotypes in their electronic health records. Fifty-four participants had variant results returned. Nineteen of these 54 participants had inherited arrhythmia syndrome diagnoses (primarily long-QT syndrome), and 12 of these 19 diagnoses were made only after variant results were returned (0.05%). After in vitro functional evaluation of 50 variants of uncertain significance, we reclassified 11 variants: 3 to likely benign and 8 to P/LP. CONCLUSIONS Genome sequencing in a large population without indication for arrhythmia genetic testing identified phenotype-positive carriers of variants in congenital arrhythmia syndrome disease genes. As the genomes of large numbers of people are sequenced, the disease risk from rare variants in arrhythmia genes can be assessed by integrating genomic screening, electronic health record phenotypes, and in vitro functional studies. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier; NCT03394859.
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Affiliation(s)
| | | | | | | | | | | | | | - Ning Shang
- Columbia University Irving Medical Center, New York NY
| | | | - Tao Yang
- Vanderbilt University Medical Center, Nashville TN
| | | | | | | | | | | | | | - Yuko Wada
- Vanderbilt University Medical Center, Nashville TN
| | - Sarah Bland
- Vanderbilt University Medical Center, Nashville TN
| | | | | | | | | | - Gail P. Jarvik
- Departments of Medicine (Medical Genetics) and Genome Sciences, University of Washington School of Medicine, Seattle, WA
| | | | | | | | | | | | | | - Bahram Namjou
- Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | - Tarek Alsaied
- Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | | | | | - Cong Liu
- Columbia University Irving Medical Center, New York NY
| | - Chunhua Weng
- Columbia University Irving Medical Center, New York NY
| | | | - James D. Ralston
- Departments of Medicine (Medical Genetics) and Genome Sciences, University of Washington School of Medicine, Seattle, WA
| | | | | | | | | | | | | | | | | | | | | | - Wei-Qi Wei
- Vanderbilt University Medical Center, Nashville TN
| | | | | | - Dan M. Roden
- Vanderbilt University Medical Center, Nashville TN
- Correspondence should be addressed to Dan M. Roden, MD, Vanderbilt University Medical Center, 2215B Garland Ave, 1285 MRBIV, Nashville, TN 37232,
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27
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Tang Girdwood SC, Rossow KM, Van Driest SL, Ramsey LB. Perspectives from the Society for Pediatric Research: pharmacogenetics for pediatricians. Pediatr Res 2022; 91:529-538. [PMID: 33824446 PMCID: PMC8492778 DOI: 10.1038/s41390-021-01499-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/12/2021] [Indexed: 12/26/2022]
Abstract
This review evaluates the pediatric evidence for pharmacogenetic associations for drugs that are commonly prescribed by or encountered by pediatric clinicians across multiple subspecialties, organized from most to least pediatric evidence. We begin with the pharmacogenetic research that led to the warning of increased risk of death in certain pediatric populations ("ultrarapid metabolizers") who are prescribed codeine after tonsillectomy or adenoidectomy. We review the evidence for genetic testing for thiopurine metabolism, which has become routine in multiple pediatric subspecialties. We discuss the pharmacogenetic research in proton pump inhibitors, for which clinical guidelines have recently been made available. With an increase in the prevalence of behavioral health disorders including attention deficit hyperactivity disorder (ADHD), we review the pharmacogenetic literature on selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and ADHD medications. We will conclude this section on the current pharmacogenetic data on ondansetron. We also provide our perspective on how to integrate the current research on pharmacogenetics into clinical care and what further research is needed. We discuss how institutions are managing pharmacogenetic test results and implementing them clinically, and how the electronic health record can be leveraged to ensure testing results are available and taken into consideration when prescribing medications. IMPACT: While many reviews of pharmacogenetics literature are available, there are few focused on pediatrics. Pediatricians across subspecialties will become more comfortable with pharmacogenetics terminology, know resources they can use to help inform their prescribing habits for drugs with known pharmacogenetic associations, and understand the limitations of testing and where further research is needed.
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Affiliation(s)
- Sonya C. Tang Girdwood
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Katelyn M. Rossow
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Laura B. Ramsey
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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28
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Williams ML, Weeks HL, Beck C, Birdwell KA, Van Driest SL, Choi L. Sensitivity of Estimated Tacrolimus Population Pharmacokinetic Profile to Assumed Dose Timing and Absorption in Real World Data and Simulated Data. Br J Clin Pharmacol 2022; 88:2863-2874. [PMID: 34997625 DOI: 10.1111/bcp.15218] [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] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022] Open
Abstract
A population pharmacokinetic (PK) study with 363 subjects was performed using real-world data extracted from electronic heath records (EHRs) to estimate the tacrolimus population PK profile. Data were extracted and built using our automated system, EHR2PKPD, suitable for quickly constructing large PK datasets from the EHR. Population PK studies for oral medications performed using EHR data often assume a regular dosing schedule as prescribed without incorporating exact dosing time. We assessed the sensitivity of the PK parameter estimates to assumptions about dose timing using last-dose times extracted by our own natural language processing system, medExtractR. We also investigated the sensitivity of estimates to absorption rate constants that are often fixed at a published value in tacrolimus population PK analyses. There was no appreciable difference in parameter estimates with assumed vs. extracted last-dose time, and our sensitivity analysis revealed little difference between parameters estimated across a range of assumed absorption rate constants. We conducted simulation studies to investigate how drug PK profiles and experimental designs such as concentration measurements design affect sensitivity to incorrect assumptions about dose timing and absorption rates. Our findings suggest that drugs with a slower elimination rate (or a longer half-life) are less sensitive to dose timing errors and that experimental designs which only allow for trough blood concentrations are usually insensitive to deviation in absorption rate.
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Affiliation(s)
- Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hannah L Weeks
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Cole Beck
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
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29
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James NT, Breeyear JH, Caprioli R, Edwards T, Hachey B, Kannankeril PJ, Keaton JM, Marshall MD, Van Driest SL, Choi L. Population Pharmacokinetic Analysis of Dexmedetomidine in Children using Real World Data from Electronic Health Records and Remnant Specimens. Br J Clin Pharmacol 2021; 88:2885-2898. [PMID: 34957589 DOI: 10.1111/bcp.15194] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/18/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Our objectives were to perform a population pharmacokinetic analysis of dexmedetomidine in children using remnant specimens and electronic health records (EHRs) and explore the impact of patient's characteristics and pharmacogenetics on dexmedetomidine clearance. METHODS Dexmedetomidine dosing and patient data were gathered from EHRs and combined with opportunistically sampled remnant specimens. Population pharmacokinetic models were developed using nonlinear mixed-effects modeling. Stage one developed a model without genotype variables; Stage two added pharmacogenetic effects. RESULTS Our final study population included 354 post-cardiac surgery patients age 0 to 22 years (median 16 months). The data were best described with a two-compartment model with allometric scaling for weight and Hill maturation function for age. Population parameter estimates and 95% confidence intervals were 27.3 L/hr (24.0 - 31.1 L/hr) for total clearance (CL), 161 L (139 - 187 L) for central compartment volume of distribution (V1 ), 26.0 L/hr (22.5 - 30.0 L/hr) for intercompartmental clearance (Q), and 7903 L (5617 - 11119 L) for peripheral compartment volume of distribution (V2 ). The estimate for postmenstrual age when 50% of adult clearance is achieved was 42.0 weeks (41.5 - 42.5 weeks) and the Hill coefficient estimate was 7.04 (6.99 - 7.08). Genotype was not statistically or clinically significant. CONCLUSION Our study demonstrates the use of real-world EHR data and remnant specimens to perform a population PK analysis and investigate covariate effects in a large pediatric population. Weight and age were important predictors of clearance. We did not find evidence for pharmacogenetic effects of UGT1A4 or UGT2B10 genotype or CYP2A6 risk score.
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Affiliation(s)
- Nathan T James
- Departments of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Todd Edwards
- Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Brian Hachey
- Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Prince J Kannankeril
- Pediatrics, Vanderbilt University Medical Center, Nashville, TN.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jacob M Keaton
- Medicine, Vanderbilt University Medical Center, Nashville, TN.,Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Matthew D Marshall
- Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L Van Driest
- Medicine, Vanderbilt University Medical Center, Nashville, TN.,Pediatrics, Vanderbilt University Medical Center, Nashville, TN.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Leena Choi
- Departments of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
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30
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Williams ML, Kannankeril PJ, Breeyear JH, Edwards TL, Van Driest SL, Choi L. Effect of CYP3A5 and CYP3A4 Genetic Variants on Fentanyl Pharmacokinetics in a Pediatric Population. Clin Pharmacol Ther 2021; 111:896-908. [PMID: 34877660 DOI: 10.1002/cpt.2506] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/03/2021] [Indexed: 12/30/2022]
Abstract
Fentanyl is an anesthetic/analgesic commonly used in surgical and recovery settings. CYP3A4 and CYP3A5 encode enzymes, which metabolize fentanyl; genetic variants in these genes impact fentanyl pharmacokinetics in adults. Pharmacokinetic (PK) studies are difficult to replicate in children due to the burden of additional blood taken solely for research purposes. The aim of this study is to test the effect of CYP3A5 and CYP3A4 genetic variants on fentanyl PKs in children using opportunistically collected samples. Fentanyl concentrations were measured from remnant blood specimens and dosing data were extracted from electronic health records. Variant data defining CYP3A4*1G and CYP3A5*3 and *6 alleles were available from prior genotyping; alleles with no variant were defined as *1. The study cohort included 434 individuals (median age 9 months, 52% male subjects) and 1,937 fentanyl concentrations were available. A two-compartment model was selected as the base model, and the final covariate model included age, weight, and surgical severity score. Clearance was significantly associated with either CYP3A5*3 or CYP3A5*6 alleles, but not the CYP3A4*1G allele. A genotype of CYP3A5*1/*3 or CYP3A5*1/*6 (i.e., intermediate metabolizer status) was associated with a 0.84-fold (95% confidence interval (CI): 0.71-1.00) reduction in clearance vs. CYP3A5*1/*1 (i.e., normal metabolizer status). CYP3A5*3/*3, CYP3A5*3/*6, or CYP3A5*6/*6 (i.e., poor metabolizer status) was associated with a 0.76-fold (95% CI: 0.58-0.99) reduction in clearance. In the final model, expected clearance was 8.9 and 6.8 L/hour for a normal and poor metabolizer, respectively, with median population covariates (9 months old, 7.7 kg, low surgical severity).
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Affiliation(s)
- Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Prince J Kannankeril
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joseph H Breeyear
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd L Edwards
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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31
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Liu M, Van Driest SL, Vnencak-Jones CL, Saucier LAG, Roland BP, Gatto CL, Just SL, Weitkamp AO, Peterson JF. Impact of Updating Pharmacogenetic Results: Lessons Learned from the PREDICT Program. J Pers Med 2021; 11:jpm11111051. [PMID: 34834403 PMCID: PMC8617828 DOI: 10.3390/jpm11111051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/09/2021] [Accepted: 10/13/2021] [Indexed: 12/26/2022] Open
Abstract
Pharmacogenomic (PGx) evidence for selective serotonin reuptake inhibitors (SSRIs) continues to evolve. For sites offering testing, maintaining up-to-date interpretations and implementing new clinical decision support (CDS) driven by existing results creates practical and technical challenges. Vanderbilt University Medical Center initiated panel testing in 2010, added CYP2D6 testing in 2017, and released CDS for SSRIs in 2020. We systematically reinterpreted historic CYP2C19 and CYP2D6 genotypes to update phenotypes to current nomenclature and to launch provider CDS and patient-oriented content for SSRIs. Chart review was conducted to identify and recontact providers caring for patients with current SSRI therapy and new actionable recommendations. A total of 15,619 patients’ PGx results were reprocessed. Of the non-deceased patients reprocessed, 21% (n = 3278) resulted in CYP2C19*1/*17 reinterpretations. Among 289 patients with an actionable recommendation and SSRI medication prescription, 31.8% (n = 92) did not necessitate contact of a clinician, while 43.2% (n = 125) resulted in clinician contacted, and for 25% (n = 72) no appropriate clinician was able to be identified. Maintenance of up-to-date interpretations and recommendations for PGx results over the lifetime of a patient requires continuous effort. Reprocessing is a key strategy for maintenance and expansion of PGx content to be periodically considered and implemented.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Correspondence:
| | - Sara L. Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (S.L.V.D.); (J.F.P.)
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Cindy L. Vnencak-Jones
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Leigh Ann G. Saucier
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (L.A.G.S.); (B.P.R.); (C.L.G.)
| | - Bartholomew P. Roland
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (L.A.G.S.); (B.P.R.); (C.L.G.)
| | - Cheryl L. Gatto
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (L.A.G.S.); (B.P.R.); (C.L.G.)
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Shari L. Just
- Health IT Decision Support and Knowledge Engineering, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Asli O. Weitkamp
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Josh F. Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (S.L.V.D.); (J.F.P.)
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
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32
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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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33
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Hertz DL, Ramsey LB, Gopalakrishnan M, Leeder JS, Van Driest SL. Analysis Approaches to Identify Pharmacogenetic Associations With Pharmacodynamics. Clin Pharmacol Ther 2021; 110:589-594. [PMID: 34043820 PMCID: PMC10947489 DOI: 10.1002/cpt.2312] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 01/01/2023]
Abstract
Pharmacogenetics (PGx) seeks to enable selection of the right dose of the right drug for each patient to optimize therapeutic outcomes. Most PGx focuses on pharmacokinetics (PKs), due to our relatively advanced understanding of the genes involved in PKs and the causative effects of variants in those genes. Genetic variants can also affect pharmacodynamics (PDs), but relatively few PGx-PD associations have been identified. This is partially due to a more limited understanding of the relevant genes and the consequences of genetic variation, but is also due in part to the potential confounding of PK variability in assessments of clinical outcomes that have a contribution from both PKs and PDs. For example, it is challenging to confirm the effect of mu opioid receptor (OPRM1) genetic variation on opioid response due to the contribution of CYP2D6 genotype to bioactivation of some opioid drugs (i.e., codeine and tramadol). The objectives of this mini-review are to describe several recent efforts to discover and validate PGx-PD that disentangle the influence of PK variability and propose potential approaches that could be used in future PGx-PD analyses. We use the effect of OPRM1 genetics on opioid response to illustrate how these analyses could be conducted and conclude by discussing how PGx-PD could be translated into clinical practice to improve therapeutic outcomes.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, United States, 48109-1065
| | - 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 United States, 45229
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, Maryland – 21201, United States
| | - J. Steven Leeder
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, United States, 64108
| | - Sara L. Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, TN, United States, 37232
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34
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Affiliation(s)
- Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ingolf Cascorbi
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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35
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Yang G, Singh S, McDonough CW, Lamba JK, Hamadeh I, Holliday LS, Wang D, Katz J, Lakatos PA, Balla B, Kosa JP, Pelliccioni GA, Price DK, Van Driest SL, Figg WD, Langaee T, Moreb JS, Gong Y. Genome-wide Association Study Identified Chromosome 8 Locus Associated with Medication-Related Osteonecrosis of the Jaw. Clin Pharmacol Ther 2021; 110:1558-1569. [PMID: 34390503 PMCID: PMC8630710 DOI: 10.1002/cpt.2397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 05/18/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022]
Abstract
Medication‐related osteonecrosis of the jaw (MRONJ) is a rare but serious drug‐related adverse event. To identify pharmacogenomic markers of MRONJ associated with bisphosphonate therapy, we conducted a genomewide association study (GWAS) meta‐analysis followed by functional analysis of 5,008 individuals of European ancestry treated with bisphosphonates, which includes the largest number of MRONJ cases to date (444 cases and 4,564 controls). Discovery GWAS was performed in randomly selected 70% of the patients with cancer and replication GWAS was performed in the remaining 30% of the patients with cancer treated with intravenous bisphosphonates followed by meta‐analysis of all 3,639 patients with cancer. GWAS was also performed in 1,369 patients with osteoporosis treated with oral bisphosphonates. The lead single‐nucleotide polymorphism (SNP), rs2736308 on chromosome 8, was associated with an increased risk of MRONJ with an odds ratio (OR) of 2.71 and 95% confidence interval (CI) of 1.90–3.86 (P = 3.57*10−8) in the meta‐analysis of patients with cancer. This SNP was validated in the MRONJ GWAS in patients with osteoporosis (OR: 2.82, 95% CI: 1.55–4.09, P = 6.84*10−4). The meta‐analysis combining patients with cancer and patients with osteoporosis yielded the same lead SNP rs2736308 on chromosome 8 as the top SNP (OR: 2.74, 95% CI: 2.09–3.39, P = 9.65*10−11). This locus is associated with regulation of the BLK, CTSB, and FDFT1 genes, which had been associated with bone mineral density. FDFT1 encodes a membrane‐associated enzyme, which is implicated in the bisphosphonate pathway. This study provides insights into the potential mechanism of MRONJ.
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Affiliation(s)
- Guang Yang
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Sonal Singh
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jatinder K Lamba
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,UF Health Cancer Center, Gainesville, Florida, USA
| | - Issam Hamadeh
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Cancer Pharmacology Department, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - L Shannon Holliday
- Department of Orthodontics, College of Dentistry, University of Florida, Gainesville, Florida, USA
| | - Danxin Wang
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Joseph Katz
- Department of Oral Medicine, College of Dentistry, University of Florida, Gainesville, Florida, USA
| | - Peter A Lakatos
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Bernadett Balla
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Janos P Kosa
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Gian Andrea Pelliccioni
- Department of Biomedical and Neuromotor Sciences - Section of Dentistry, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Douglas K Price
- Genitourinary Malignancies Branch National Cancer Institute, Bethesda, Maryland, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William D Figg
- Genitourinary Malignancies Branch National Cancer Institute, Bethesda, Maryland, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jan S Moreb
- Hematology, Transplantation and Cellular Therapy Department, Novant Health Cancer Institute, Winston-Salem, North Carolina, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,UF Health Cancer Center, Gainesville, Florida, USA
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Van Driest SL, Abul-Husn NS, Glessner JT, Bastarache L, Nirenberg S, Schildcrout JS, Eswarappa MS, Belbin GM, Shaffer CM, Mentch F, Connolly J, Shi M, Stein CM, Roden DM, Hakonarson H, Cox NJ, Borinstein SC, Mosley JD. Association Between a Common, Benign Genotype and Unnecessary Bone Marrow Biopsies Among African American Patients. JAMA Intern Med 2021; 181:1100-1105. [PMID: 34180972 PMCID: PMC8239990 DOI: 10.1001/jamainternmed.2021.3108] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Up to two-thirds of African American individuals carry the benign rs2814778-CC genotype that lowers total white blood cell (WBC) count. OBJECTIVE To examine whether the rs2814778-CC genotype is associated with an increased likelihood of receiving a bone marrow biopsy (BMB) for an isolated low WBC count. DESIGN, SETTING, AND PARTICIPANTS This retrospective genetic association study assessed African American patients younger than 90 years who underwent a BMB at Vanderbilt University Medical Center, Mount Sinai Health System, or Children's Hospital of Philadelphia from January 1, 1998, to December 31, 2020. EXPOSURE The rs2814778-CC genotype. MAIN OUTCOMES AND MEASURES The proportion of individuals with the CC genotype who underwent BMB for an isolated low WBC count and had a normal biopsy result compared with the proportion of individuals with the CC genotype who underwent BMB for other indications and had a normal biopsy result. RESULTS Among 399 individuals who underwent a BMB (mean [SD] age, 41.8 [22.5] years, 234 [59%] female), 277 (69%) had the CC genotype. A total of 35 patients (9%) had clinical histories of isolated low WBC counts, and 364 (91%) had other histories. Of those with a clinical history of isolated low WBC count, 34 of 35 (97%) had the CC genotype vs 243 of 364 (67%) of those without a low WBC count history. Among those with the CC genotype, 33 of 34 (97%) had normal results for biopsies performed for isolated low WBC counts compared with 134 of 243 individuals (55%) with biopsies performed for other histories (P < .001). CONCLUSIONS AND RELEVANCE In this genetic association study, among patients of African American race who had a BMB with a clinical history of isolated low WBC counts, the rs2814778-CC genotype was highly prevalent, and 97% of these BMBs identified no hematologic abnormality. Accounting for the rs2814778-CC genotype in clinical decision-making could avoid unnecessary BMB procedures.
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Affiliation(s)
- Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noura S Abul-Husn
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph T Glessner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,The Center for Applied Genomics, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon Nirenberg
- Department of Scientific Computing, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Meghana S Eswarappa
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gillian M Belbin
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christian M Shaffer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank Mentch
- The Center for Applied Genomics, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John Connolly
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hakon Hakonarson
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy J Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott C Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
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Kannankeril PJ, Radbill AE, Van Driest SL, Smith AH, Fish FA. B-PO04-189 DO CONGENITAL HEART SURGERY MORTALITY RISK SCORES PREDICT RISK FOR POSTOPERATIVE ARRHYTHMIAS? Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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38
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Muhammad A, Aka IT, Birdwell KA, Gordon AS, Roden DM, Wei WQ, Mosley JD, Van Driest SL. Genome-Wide Approach to Measure Variant-Based Heritability of Drug Outcome Phenotypes. Clin Pharmacol Ther 2021; 110:714-722. [PMID: 34151428 DOI: 10.1002/cpt.2323] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/16/2021] [Indexed: 12/18/2022]
Abstract
Pharmacogenomic studies have successfully identified variants-typically with large effect sizes in drug target and metabolism enzymes-that predict drug outcome phenotypes. However, these variants may account for a limited proportion of phenotype variability attributable to the genome. Using genome-wide common variation, we measured the narrow-sense heritability ( h SNP 2 ) of seven pharmacodynamic and five pharmacokinetic phenotypes across three cardiovascular drugs, two antibiotics, and three immunosuppressants. We used a Bayesian hierarchical mixed model, BayesR, to model the distribution of genome-wide variant effect sizes for each drug phenotype as a mixture of four normal distributions of fixed variance (0, 0.01%, 0.1%, and 1% of the total additive genetic variance). This model allowed us to parse h SNP 2 into bins representing contributions of no-effect, small-effect, moderate-effect, and large-effect variants, respectively. For the 12 phenotypes, a median of 969 (range 235-6,304) unique individuals of European ancestry and a median of 1,201,626 (range 777,427-1,514,275) variants were included in our analyses. The number of variants contributing to h SNP 2 ranged from 2,791 to 5,356 (median 3,347). Estimates for h SNP 2 ranged from 0.05 (angiotensin-converting enzyme inhibitor-induced cough) to 0.59 (gentamicin concentration). Small-effect and moderate-effect variants contributed a majority to h SNP 2 for every phenotype (range 61-95%). We conclude that drug outcome phenotypes are highly polygenic. Thus, larger genome-wide association studies of drug phenotypes are needed both to discover novel variants and to determine how genome-wide approaches may improve clinical prediction of drug outcomes.
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Affiliation(s)
- Ayesha Muhammad
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ida T Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam S Gordon
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA.,Center for Genetic Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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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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40
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Luzum JA, Petry N, Taylor AK, Van Driest SL, Dunnenberger HM, Cavallari LH. Moving Pharmacogenetics Into Practice: It's All About the Evidence! Clin Pharmacol Ther 2021; 110:649-661. [PMID: 34101169 DOI: 10.1002/cpt.2327] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022]
Abstract
The evidence for pharmacogenetics has grown rapidly in recent decades. However, the strength of evidence required for the clinical implementation of pharmacogenetics is highly debated. Therefore, the purpose of this review is to summarize different perspectives on the evidence required for the clinical implementation of pharmacogenetics. First, we present two patient cases that demonstrate how knowledge of pharmacogenetic evidence affected their care. Then we summarize resources that curate pharmacogenetic evidence, types of evidence (with an emphasis on randomized controlled trials [RCT]) and their limitations, and different perspectives from implementers, clinicians, and patients. We compare pharmacogenetics to a historical example (i.e., the evidence required for the clinical implementation of pharmacokinetics/therapeutic drug monitoring), and we provide future perspectives on the evidence for pharmacogenetic panels and the need for more education in addition to evidence. Although there are differences in the interpretation of pharmacogenetic evidence across resources, efforts for standardization are underway. Survey data illustrate the value of pharmacogenetic testing from the patient perspective, with their providers seen as key to ensuring maximum benefit from test results. However, clinicians and practice guidelines from medical societies often rely on RCT data to guide treatment decisions, which are not always feasible or ethical in pharmacogenetics. Thus, recognition of other types of evidence to support pharmacogenetic implementation is needed. Among pharmacogenetic implementers, consistent evidence of pharmacogenetic associations is deemed most critical. Ultimately, moving pharmacogenetics into practice will require consideration of multiple stakeholder perspectives, keeping particularly attuned to the voice of the ultimate stakeholder-the patient.
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Affiliation(s)
- Jasmine A Luzum
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Natasha Petry
- Department of Pharmacy Practice, College of Health Professions, North Dakota State University, Fargo, North Dakota, USA.,Sanford Imagenetics, Sioux Falls, South Dakota, USA
| | - Annette K Taylor
- Colorado Coagulation, Laboratory Corporation of America Holdings, Englewood, Colorado, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Ramsey LB, Namerow LB, Bishop JR, Hicks JK, Bousman C, Croarkin PE, Mathews CA, Van Driest SL, Strawn JR. Thoughtful Clinical Use of Pharmacogenetics in Child and Adolescent Psychopharmacology. J Am Acad Child Adolesc Psychiatry 2021; 60:660-664. [PMID: 32860906 PMCID: PMC8141104 DOI: 10.1016/j.jaac.2020.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 04/21/2020] [Revised: 07/24/2020] [Accepted: 08/19/2020] [Indexed: 12/27/2022]
Abstract
AACAP's recent policy statement on Clinical Use of Pharmacogenetic Tests in Prescribing Psychotropic Medications for Children and Adolescents1 recommends that "clinicians avoid using pharmacogenetic testing to select psychotropic medications in children and adolescents." We agree that there are limitations to the nascent evidence base for using pharmacogenetics, especially in combinatorial form (eg, test results that bin medications based on multiple genes). However, all-or-nothing recommendations fail to recognize the nuance and context of this testing and contrast with the AACAP Facts for Families on pharmacogenetic testing. Moreover, pharmacogenetic testing may inform dosing for antidepressants that are commonly used in child and adolescent psychiatry (eg, sertraline, escitalopram, citalopram, fluvoxamine) as well as the tolerability of some psychotropic medications. With this in mind, we wish to remind the AACAP community of the accumulating evidence and to highlight important principles of pharmacogenetic testing in youths. Specifically: 1) pharmacogenetic testing is not always performed by commercial companies and is not always combinatorial; 2) dosing recommendations or assessment of risk for severe hypersensitivity reactions are based on pharmacogenetics in the Food and Drug Administration (FDA)-approved product inserts for several medications commonly prescribed to children (eg, citalopram, aripiprazole, atomoxetine, carbamazepine, oxcarbazepine at www.fda.gov/drugs/science-and-research-drugs/table-pharmacogenomic-biomarkers-drug-labeling); 3) expert consensus guidelines for dosing or identifying hypersensitivity risk for these drugs are available from the National Institutes of Health (NIH)-supported Clinical Pharmacogenetics Implementation Consortium (CPIC, www.cpicpgx.org/), which provides transparent, regularly updated, and evidence-based evaluations of pharmacogenetic data;2 and 4) randomized trials are not required for clinical dose adjustments; for example, dose adjustments because of decreased hepatic function or concomitant interacting medications are based on pharmacokinetic data, similar to many pharmacokinetic gene-based recommendations from CPIC.
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Affiliation(s)
- Laura B Ramsey
- Cincinnati Children's Hospital Medical Center, Ohio; University of Cincinnati, Ohio
| | - Lisa B Namerow
- University of Connecticut School of Medicine, Farmington; Institute of Living/Hartford Hospital, Hartford, Connecticut
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Rossow KM, Vaughn SE, Strawn JR, Van Driest SL, Ramsey LB. The need for a refined understanding of CYP2D6 in second-generation antipsychotic outcomes in children and adolescents. Pharmacogenomics 2021; 22:447-450. [PMID: 34032507 DOI: 10.2217/pgs-2021-0049] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Tweetable abstract High-quality studies examining the influence of CYP2D6 on the exposure and tolerability of antipsychotics in youth are needed to mitigate the limitations of prior studies.
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Affiliation(s)
- Katelyn M Rossow
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Samuel E Vaughn
- Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Jeffrey R Strawn
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45219, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Laura B Ramsey
- Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45219, USA
- Department of Pediatrics, Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
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Rossow KM, Oshikoya KA, Aka IT, Maxwell-Horn AC, Roden DM, Van Driest SL. Evidence for Pharmacogenomic Effects on Risperidone Outcomes in Pediatrics. J Dev Behav Pediatr 2021; 42:205-212. [PMID: 33759847 PMCID: PMC7995603 DOI: 10.1097/dbp.0000000000000883] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the association between genetic variants reported to affect risperidone and adverse events (AEs) in children and adolescents. METHODS Individuals aged 18 years or younger with ≥4 weeks of risperidone exposure in a deidentified DNA biobank were included. The primary outcome was AE frequency as a function of genotype. Individuals were classified according to metabolizer status for CYP2D6, CYP3A4, and CYP3A5; wild type, heterozygote, or homozygote for specific single nucleotide variants for DRD2, DRD3, HTR2A, and HTR2C; and wild type versus nonwild type for multiple uncommon variants in ABCG2, ABCB1, and HTR2C. Tests of association of each classification to AEs were performed using a Fisher exact test and logistic regression, and statistically significant classifications were included in a final logistic regression. RESULTS The final cohort included 257 individuals. AEs were more common in CYP2D6 poor/intermediate metabolizers (PMs/IMs) than normal/rapid/ultrarapid metabolizers (NMs/RMs/UMs) in univariate and multivariate analysis. HTR2A-rs6311 heterozygotes and homozygotes had fewer AEs than wild types in logistic regression but not in univariate analysis. In the final multivariable model adjusting for age, race, sex, and risperidone dose, AEs were associated with CYP2D6 (adjusted odds ratio [AOR] 2.6, 95% CI 1.1-5.5, for PMs/IMs vs. NMs/RMs/UMs) and HTR2A-rs6311 (AOR 0.6, 95% CI 0.4-0.9, for each variant allele), both consistent with previous studies. CONCLUSION Children and adolescents who are CYP2D6 PMs/IMs may have an increased risk for risperidone AEs. Of the genes and variants studied, only CYP2D6 has consistent association and sufficient data for clinical use, whereas HTR2A-rs6311 has limited data and requires further study.
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Affiliation(s)
| | | | | | | | - Dan M Roden
- Departments of Pediatrics
- Medicine, and
- Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
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Ginsburg GS, Cavallari LH, Chakraborty H, Cooper-DeHoff RM, Dexter PR, Eadon MT, Ferket BS, Horowitz CR, Johnson JA, Kannry J, Kucher N, Madden EB, Orlando LA, Parker W, Peterson J, Pratt VM, Rakhra-Burris TK, Ramos MA, Skaar TC, Sperber N, Steen-Burrell KA, Van Driest SL, Voora D, Wiisanen K, Winterstein AG, Volpi S. Establishing the value of genomics in medicine: the IGNITE Pragmatic Trials Network. Genet Med 2021; 23:1185-1191. [PMID: 33782552 PMCID: PMC8263480 DOI: 10.1038/s41436-021-01118-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 09/28/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE A critical gap in the adoption of genomic medicine into medical practice is the need for the rigorous evaluation of the utility of genomic medicine interventions. METHODS The Implementing Genomics in Practice Pragmatic Trials Network (IGNITE PTN) was formed in 2018 to measure the clinical utility and cost-effectiveness of genomic medicine interventions, to assess approaches for real-world application of genomic medicine in diverse clinical settings, and to produce generalizable knowledge on clinical trials using genomic interventions. Five clinical sites and a coordinating center evaluated trial proposals and developed working groups to enable their implementation. RESULTS Two pragmatic clinical trials (PCTs) have been initiated, one evaluating genetic risk APOL1 variants in African Americans in the management of their hypertension, and the other to evaluate the use of pharmacogenetic testing for medications to manage acute and chronic pain as well as depression. CONCLUSION IGNITE PTN is a network that carries out PCTs in genomic medicine; it is focused on diversity and inclusion of underrepresented minority trial participants; it uses electronic health records and clinical decision support to deliver the interventions. IGNITE PTN will develop the evidence to support (or oppose) the adoption of genomic medicine interventions by patients, providers, and payers.
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Affiliation(s)
- Geoffrey S Ginsburg
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA.
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | | | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Paul R Dexter
- School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Michael T Eadon
- Division of Clinical Pharmacology, Indiana University, Indianapolis, IN, USA
| | - Bart S Ferket
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| | - Carol R Horowitz
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Joseph Kannry
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| | - Natalie Kucher
- Division of Genomic Medicine, National Human Genome Research Institute, NIH, Bethesda, MD, USA
| | - Ebony B Madden
- Division of Genomic Medicine, National Human Genome Research Institute, NIH, Bethesda, MD, USA
| | - Lori A Orlando
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA
| | - Wanda Parker
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Josh Peterson
- Department of Biomedical Informatics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, IN, USA
| | | | - Michelle A Ramos
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| | - Todd C Skaar
- Division of Clinical Pharmacology, Indiana University, Indianapolis, IN, USA
| | - Nina Sperber
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke Margolis Center for Health Policy, Durham VA Health Services Research & Development Service, Duke Center for Applied Genomics & Precision Medicine, Durham, NC, USA
| | | | - Sara L Van Driest
- Department of Pediatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deepak Voora
- Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC, USA
| | - Kristin Wiisanen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Simona Volpi
- Division of Genomic Medicine, National Human Genome Research Institute, NIH, Bethesda, MD, USA
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Crews KR, Monte AA, Huddart R, Caudle KE, Kharasch ED, Gaedigk A, Dunnenberger HM, Leeder JS, Callaghan JT, Samer CF, Klein TE, Haidar CE, Van Driest SL, Ruano G, Sangkuhl K, Cavallari LH, Müller DJ, Prows CA, Nagy M, Somogyi AA, Skaar TC. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2D6, OPRM1, and COMT Genotypes and Select Opioid Therapy. Clin Pharmacol Ther 2021; 110:888-896. [PMID: 33387367 DOI: 10.1002/cpt.2149] [Citation(s) in RCA: 177] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/02/2020] [Indexed: 11/08/2022]
Abstract
Opioids are mainly used to treat both acute and chronic pain. Several opioids are metabolized to some extent by CYP2D6 (codeine, tramadol, hydrocodone, oxycodone, and methadone). Polymorphisms in CYP2D6 have been studied for an association with the clinical effect and safety of these drugs. Other genes that have been studied for their association with opioid clinical effect or adverse events include OPRM1 (mu receptor) and COMT (catechol-O-methyltransferase). This guideline updates and expands the 2014 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 genotype and codeine therapy and includes a summation of the evidence describing the impact of CYP2D6, OPRM1, and COMT on opioid analgesia and adverse events. We provide therapeutic recommendations for the use of CYP2D6 genotype results for prescribing codeine and tramadol and describe the limited and/or weak data for CYP2D6 and hydrocodone, oxycodone, and methadone, and for OPRM1 and COMT for clinical use.
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Affiliation(s)
- Kristine R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Andrew A Monte
- Department of Emergency Medicine & Colorado Center for Personalized Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Kelly E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kanas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Henry M Dunnenberger
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kanas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John T Callaghan
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caroline Flora Samer
- Clinical Pharmacology and Toxicology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Cyrine E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gualberto Ruano
- Institute of Living Hartford Hospital, Genomas Lab of Personalized Health, University of Connecticut School of Medicine and University of Puerto Rico Medical Sciences, Hartford, Connecticut, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Daniel J Müller
- Department of Psychiatry, Campbell Family Mental Health Research Institute of CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mohamed Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt 57357, Cairo, Egypt
| | - Andrew A Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Schulte RR, Choi L, Utreja N, Van Driest SL, Stein CM, Ho RH. Effect of SLCO1B1 Polymorphisms on High-Dose Methotrexate Clearance in Children and Young Adults With Leukemia and Lymphoblastic Lymphoma. Clin Transl Sci 2021; 14:343-353. [PMID: 32961024 PMCID: PMC7877862 DOI: 10.1111/cts.12879] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 02/04/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Abstract
High-dose (HD) methotrexate (MTX) is a critical component of treatment for hematologic malignancies in children and young adults. Therapeutic drug monitoring is necessary due to substantial interindividual variation in MTX clearance. Common function-altering polymorphisms in SLCO1B1 (encodes OATP1B1, which transports MTX) may contribute to clearance variability. We performed pharmacokinetic modeling using data for 106 children and young adults treated with HD MTX for hematologic malignancies; of 396 total courses of HD MTX, 360 consisted of 5 g/m2 over 24 hours. We evaluated the contribution of clinical covariates and SLCO1B1 genotype (388A>G and 521T>C) to MTX clearance variability. Of the clinical covariates studied, patient weight improved the pharmacokinetic model most significantly (P < 0.001). The addition of the SLCO1B1 variants individually further improved the model (P < 0.05 for each). An interaction between these variants was suggested when both were included (P = 0.017). SLCO1B1 genotype should be considered in efforts to personalize HD MTX dosing.
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Affiliation(s)
- Rachael R. Schulte
- Department of PediatricsDivision of Pediatric Hematology/OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA,Present address:
Department of PediatricsDivision of Pediatric Hematology/OncologyRiley Hospital for Children at IU Health and Indiana University School of MedicineIndianapolisIndianaUSA
| | - Leena Choi
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Nipun Utreja
- Department of PediatricsDivision of Pediatric Hematology/OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sara L. Van Driest
- Department of PediatricsDivision of General PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - C. Michael Stein
- Department of MedicineDivision of Clinical PharmacologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Richard H. Ho
- Department of PediatricsDivision of Pediatric Hematology/OncologyVanderbilt University Medical CenterNashvilleTennesseeUSA
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47
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Brown JT, Ramsey LB, Van Driest SL, Aka I, Colace SI. Characterizing Pharmacogenetic Testing Among Children's Hospitals. Clin Transl Sci 2020; 14:692-701. [PMID: 33325650 PMCID: PMC7993279 DOI: 10.1111/cts.12931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 06/11/2020] [Accepted: 10/12/2020] [Indexed: 12/27/2022] Open
Abstract
Although pharmacogenetic testing is becoming increasingly common across medical subspecialties, a broad range of utilization and implementation exists across pediatric centers. Large pediatric institutions that routinely use pharmacogenetics in their patient care have published their practices and experiences; however, minimal data exist regarding the full spectrum of pharmacogenetic implementation among children’s hospitals. The primary objective of this nationwide survey was to characterize the availability, concerns, and barriers to pharmacogenetic testing in children’s hospitals in the Children’s Hospital Association. Initial responses identifying a contact person were received from 18 institutions. Of those 18 institutions, 14 responses (11 complete and 3 partial) to a more detailed survey regarding pharmacogenetic practices were received. The majority of respondents were from urban institutions (72%) and held a Doctor of Pharmacy degree (67%). Among all respondents, the three primary barriers to implementing pharmacogenetic testing identified were test reimbursement, test cost, and money. Conversely, the three least concerning barriers were potential for genetic discrimination, sharing results with family members, and availability of tests in certified laboratories. Low‐use sites rated several barriers significantly higher than the high‐use sites, including knowledge of pharmacogenetics (P = 0.03), pharmacogenetic interpretations (P = 0.04), and pharmacogenetic‐based changes to therapy (P = 0.03). In spite of decreasing costs of pharmacogenetic testing, financial barriers are one of the main barriers perceived by pediatric institutions attempting clinical implementation. Low‐use sites may also benefit from education/outreach in order to reduce perceived barriers to implementation.
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Affiliation(s)
- Jacob T Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota Duluth, Duluth, Minnesota, USA
| | - Laura B Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan I Colace
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
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48
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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: 33] [Impact Index Per Article: 8.3] [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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49
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Rossow KM, Aka IT, Maxwell-Horn AC, Roden DM, Van Driest SL. Pharmacogenetics to Predict Adverse Events Associated With Antidepressants. Pediatrics 2020; 146:peds.2020-0957. [PMID: 33234666 PMCID: PMC7786826 DOI: 10.1542/peds.2020-0957] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the association between cytochrome P450 2C19 (CYP2C19) metabolizer status and risk for escitalopram and citalopram, collectively termed (es)citalopram, and sertraline adverse events (AEs) in children. METHODS In this retrospective cohort study, we used deidentified electronic health records linked to DNA. The cohort included children ≤18 years with ≥2 days of (es)citalopram or ≥7 days of sertraline exposure. The primary outcome was AEs assessed by manual chart review. CYP2C19 was genotyped for functional variants (*2, *3, *4, *6, *8, and *17), and individuals were assigned metabolizer status. Association between AEs and metabolizer status was determined by using Cox regression adjusting for age, race, ethnicity, dose, and concomitant CYP2C19-inhibiting medications. RESULTS The cohort included 249 sertraline-exposed and 458 (es)citalopram-exposed children, with a median age of 14.2 years (interquartile range 11.2-16.2) and 13.4 years (interquartile range 10.1-15.9), respectively. Sertraline AEs were more common in normal metabolizers (NMs) compared to poor metabolizers (PMs) or intermediate metabolizers (IMs) (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.01-3.2; P = .047) in unadjusted analysis and after adjustment (HR 1.9; CI 1.04-3.4; P = .04). For (es)citalopram, more AEs were observed in NMs than PMs and IMs without statistically significant differences (unadjusted HR 1.6; CI 0.95-2.6; P = .08; adjusted HR 1.6; CI 0.95-2.6; P = .08). CONCLUSIONS In contrast to adults, in our pediatric cohort, CYP2C19 NMs experienced increased sertraline AEs than PMs and IMs. (Es)citalopram AEs were not associated with CYP2C19 status in the primary analysis. The mechanism underlying this pediatric-specific finding is unknown but may be related to physiologic differences of adolescence. Further research is required to inform genotype-guided prescribing for these drugs in children.
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Affiliation(s)
| | - Ida T. Aka
- Departments of Pediatrics,,Contributed equally as co-first authors
| | | | - Dan M. Roden
- Medicine,,Pharmacology, and,Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, Tennessee
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50
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Liu M, Vnencak-Jones CL, Roland BP, Gatto CL, Mathe JL, Just SL, Peterson JF, Van Driest SL, Weitkamp AO. A Tutorial for Pharmacogenomics Implementation Through End-to-End Clinical Decision Support Based on Ten Years of Experience from PREDICT. Clin Pharmacol Ther 2020; 109:101-115. [PMID: 33048353 DOI: 10.1002/cpt.2079] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/25/2020] [Indexed: 12/24/2022]
Abstract
Vanderbilt University Medical Center implemented pharmacogenomics (PGx) testing with the Pharmacogenomic Resource for Enhanced Decisions in Care and Treatment (PREDICT) initiative in 2010. This tutorial reviews the laboratory considerations, technical infrastructure, and programmatic support required to deliver panel-based PGx testing across a large health system with examples and experiences from the first decade of the PREDICT initiative. From the time of inception, automated clinical decision support (CDS) has been a critical capability for delivering PGx results to the point-of-care. Key features of the CDS include human-readable interpretations and clinical guidance that is anticipatory, actionable, and adaptable to changes in the scientific literature. Implementing CDS requires that structured results from the laboratory be encoded in standards-based messages that are securely ingested by electronic health records. Translating results to guidance also requires an informatics infrastructure with multiple components: (1) to manage the interpretation of raw genomic data to "star allele" results to expected phenotype, (2) to define the rules that associate a phenotype with recommended changes to clinical care, and (3) to manage and update the knowledge base. Knowledge base management is key to processing new results with the latest guidelines, and to ensure that historical genomic results can be reinterpreted with revised CDS. We recommend that these components be deployed with institutional authorization, programmatic support, and clinician education to govern the CDS content and policies around delivery.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cindy L Vnencak-Jones
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bartholomew P Roland
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janos L Mathe
- Health IT Decision Support and Knowledge Engineering, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shari L Just
- Health IT Decision Support and Knowledge Engineering, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Josh F Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Asli O Weitkamp
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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