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Scodellaro S, Cohn RD, Cohn I. Urgent call for guidance supporting gene-based drug dosing in children and adolescents. Paediatr Child Health 2023; 28:205-245. [PMID: 37287475 PMCID: PMC10243970 DOI: 10.1093/pch/pxad003] [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: 05/04/2022] [Accepted: 01/12/2023] [Indexed: 06/09/2023] Open
Abstract
In the past decade, there have been tremendous advancements in the field of genomics that have led to significant progress in redefining the concept of precision medicine. Pharmacogenetics (PGx) is one of the most promising areas of precision medicine and is the 'low hanging fruit' of this individualized approach to medication dosing and selection. Although a variety of regulatory health agencies and professional consortia have established PGx clinical practice guidelines, implementation has been slow given numerous barriers faced by health care professionals. Many lack the training needed to interpret PGx and there are no paediatric specific guidelines. As the field of PGx continues to grow, an emphasis on collaborative inter-professional education, coupled with ongoing efforts to increase accessibility to advancing testing technology are necessary to translate this branch of precision medicine from the bench to the bedside.
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Affiliation(s)
- Sierra Scodellaro
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald D Cohn
- Genetics and Genome Biology Program, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical and Metabolic and Genetics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Iris Cohn
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
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Pan A, Scodellaro S, Khan T, Ushcatz I, Wu W, Curtis M, Cohen E, Cohn RD, Hayeems RZ, Meyn MS, Orkin J, Otal J, Reuter MS, Walker S, Scherer SW, Marshall CR, Cohn I, Costain G. Pharmacogenetic profiling via genome sequencing in children with medical complexity. Pediatr Res 2023; 93:905-910. [PMID: 36167815 PMCID: PMC10033400 DOI: 10.1038/s41390-022-02313-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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] [Received: 12/30/2021] [Revised: 07/25/2022] [Accepted: 09/03/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) are a priority pediatric population, with high resource use and associated costs. Genome-wide sequencing is increasingly organized for CMC early in life as a diagnostic test. Polypharmacy becomes common as CMC age. Clinically relevant pharmacogenetic (PGx) information can be extracted from existing genome sequencing (GS) data via GS-PGx profiling. The role of GS-PGx profiling in the CMC population is unclear. METHODS Prescribed medications were extracted from care plans of 802 eligible CMC enrolled in a structured Complex Care Program over a 10-year period. Drug-gene associations were annotated using curated Clinical Pharmacogenetics Implementation Consortium data. GS-PGx profiling was then performed for a subset of 50 CMC. RESULTS Overall, 546 CMC (68%) were prescribed at least one medication with an established PGx association. In the GS-PGx subgroup, 24 (48%) carried variants in pharmacogenes with drug-gene guidelines for one or more of their current medications. All had findings of potential relevance to some medications, including 32 (64%) with variants in CYP2C19 that could affect their metabolism of proton-pump inhibitors. CONCLUSION GS-PGx profiling at the time of diagnostics-focused genetic testing could be an efficient way to incorporate precision prescribing practices into the lifelong care of CMC. IMPACT Polypharmacy and genetic test utilization are both common in children with medical complexity. The role of repurposing genome sequencing data for pharmacogenetic profiling in children with medical complexity was previously unclear. We identified a high rate of medication use with clinically relevant drug-gene associations in this priority pediatric population and demonstrated that relevant pharmacogenetic information can be extracted from their existing genome sequencing data. Pharmacogenetic profiling at the time of diagnostics-focused genetic testing could be an efficient way to incorporate precision prescribing practices into the lifelong care of children with medical complexity.
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Affiliation(s)
- Amy Pan
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sierra Scodellaro
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Tayyaba Khan
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Inna Ushcatz
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Wendy Wu
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Meredith Curtis
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, ON, Canada
| | - Ronald D Cohn
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Robin Z Hayeems
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Stephen Meyn
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Center for Human Genomics and Precision Medicine, University of Wisconsin, Madison, WI, USA
| | - Julia Orkin
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jaskiran Otal
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Miriam S Reuter
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Susan Walker
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephen W Scherer
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christian R Marshall
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
- Genome Diagnostics, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Iris Cohn
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Gregory Costain
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada.
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Bortolin KA, Cohn I, Da Silva S, Ito S, Marcon P, Afzal N, Scodellaro S, Verstegen R, Hulst J. A129 CYP2C19 PHARMACOGENETIC TESTING IN PAEDIATRIC PATIENTS WITH EOSINOPHILIC ESOPHAGITIS INFLUENCES DOSING OF PROTON-PUMP-INHIBITORS AND RESPONSE TO THERAPY. J Can Assoc Gastroenterol 2022. [PMCID: PMC8859342 DOI: 10.1093/jcag/gwab049.128] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder that can be treated with a proton pump inhibitor (PPI). Pharmacogenetics (PGx) is the study of how variations in an individual’s genome influences drug response. Genetic variation in the metabolism gene CYP2C19 can produce differences in enzyme activity which is known to be a contributing factor for therapeutic failure with PPI treatment. Use of 2nd generation PPI (rabeprazole) can be beneficial in some as this PPI is less effected by CYP2C19 metabolism. PGx has been studied in PPI therapy for peptic ulcer disease but has not been demonstrated in patients with EoE. Aims To describe the CYP2C19 metabolism in patients with EoE on PPI and to estimate the clinical utility of PGx testing in directing subsequent changes in therapy with improvement in remission rates. Methods Interim analyses of a single centre, non-interventional, ongoing descriptive pilot study investigating CYP2C19 metabolism in patients with EoE, as part of a larger PGx pilot study and EoE- AHEAD Registry Study at SickKids. Patients with EoE that were newly diagnosed and started PPI or those not in remission on current non-PPI therapy or not in remission on dose PPI (2 mg/kg/day, max 30 mg lansoprazole BID) were included. Active disease was defined as a peak eosinophil count >15/hpf. Results 37 patients met the inclusion criteria with completed PGx test; mean age was 13 years, 29(78%) were male, and 13(35%) had concurrent atopic disease. PGx testing showed that 12(32%) and 4(11%) were rapid (RM) and ultrarapid metabolizers (URM) respectively (Fig.1), which is significantly higher than the population average. Of this subgroup, 9 started rabeprazole, 3 had a lansoprazole dose increase, and 4 had no changes. Overall, changes in therapy based on PGx testing were made in 29(78%) patients, 8 are awaiting follow-up (Fig 2). Currently, the patients with available repeat biopsy results after PGx test-guided therapy changes is limited due COVID-19 related delays in endoscopies. Conclusions The preliminary findings of our study using PGx to guide PPI dosing in pediatric patients with EoE demonstrate that PGx test results lead to a change in clinical management in most patients. In RM and URM, PGx results trigger an adjustment of PPI dose or type could lead to earlier disease remission in PPI-responsive patients, thereby optimizing PPI efficacy. PGx may support dose reduction in poor metabolizers aiming to avoid long-term adverse events. Further correlation with endoscopy and histology findings of patients after PGx-guided therapy changes will follow. Furthermore, it is important to examine if CYP2C19 variant information available before PPI therapy further streamlines an initial phase of the treatment. ![]()
Funding Agencies Dr. Marcon: J Garfield Campbell Fund, Dr. Hulst: Start-up Funds from the Department of Pediatrics at SickKids
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Affiliation(s)
- K A Bortolin
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, Toronto, ON, Canada
| | - I Cohn
- The Hospital for Sick Children, Division of Clinical Pharmacology and Toxicology, Toronto, ON, Canada
| | - S Da Silva
- University of Toronto, Toronto, ON, Canada
| | - S Ito
- The Hospital for Sick Children, Division of Clinical Pharmacology and Toxicology, Toronto, ON, Canada
| | - P Marcon
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, Toronto, ON, Canada
| | - N Afzal
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, Toronto, ON, Canada
| | - S Scodellaro
- The Hospital for Sick Children, Division of Clinical Pharmacology and Toxicology, Toronto, ON, Canada
| | - R Verstegen
- The Hospital for Sick Children, Division of Clinical Pharmacology and Toxicology, Toronto, ON, Canada
| | - J Hulst
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, Toronto, ON, Canada
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