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Cavallari LH, Limdi NA, Beitelshees AL, Lee JC, Duarte JD, Franchi F, Tuteja S, Giri J, Empey PE, Kreutz RP, Skaar TC, Allen JM, Coons JC, Gong Y, McDonough CW, Stevenson JM, Thomas CD, Johnson JA, Stouffer GA, Angiolillo DJ, Lee CR. Evaluation of Potential Racial Disparities in CYP2C19-Guided P2Y 12 Inhibitor Prescribing After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2023; 113:615-623. [PMID: 36306392 PMCID: PMC9957848 DOI: 10.1002/cpt.2776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/21/2022] [Indexed: 01/16/2023]
Abstract
Black patients suffer worse outcomes after percutaneous coronary intervention (PCI) than White patients. Inequities in antiplatelet prescribing may contribute to this health disparity. We compared P2Y12 inhibitor prescribing by race following CYP2C19 genotyping to guide antiplatelet therapy selection after PCI. Patients from 9 sites that performed clinical CYP2C19 genotyping after PCI were included. Alternative therapy (e.g., prasugrel or ticagrelor) was recommended for CYP2C19 no-function allele carriers, in whom clopidogrel is predicted to be less effective. The primary outcome was choice of P2Y12 inhibitor (clopidogrel vs. alternative therapy) based on genotype. Of 3,342 patients included, 2,448 (73%) were White, and 659 (20%) were Black. More Black than White patients had a no-function allele (34.3% vs. 29.7%, P = 0.024). At hospital discharge following PCI, 44.2% of Black and 44.0% of White no-function allele carriers were prescribed alternative therapy. At the time of the last follow-up within 12 months, numerically fewer Black (51.8%) than White (56.7%) no-function allele carriers were prescribed alternative therapy (P = 0.190). However, the difference was not significant after accounting for other factors associated with P2Y12 inhibitor selection (odds ratio 0.79, 95% confidence interval 0.58-1.08). Alternative therapy use did not differ between Black (14.3%) and White (16.7%) patients without a no-function allele (P = 0.232). Among real-world patients who received CYP2C19 testing after PCI, P2Y12 inhibitor prescribing rates did not differ between Black and White patients. Our data suggest an absence of racial disparity in genotype-guided antiplatelet prescribing among patients receiving CYP2C19 testing.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Nita A. Limdi
- Department of Neurology, Program for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, AL
| | - Amber L. Beitelshees
- University of Maryland School of Medicine, Department of Medicine and Program for Personalized and Genomic Medicine, Baltimore, MD
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | | | - Todd C. Skaar
- Indiana University School of Medicine, Indianapolis, IN
| | - John M. Allen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando, FL
| | - James C. Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
| | | | - Craig R. Lee
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Cicali EJ, Lemke L, Al Alshaykh H, Nguyen K, Cavallari LH, Wiisanen K. How to Implement a Pharmacogenetics Service at your Institution. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022; 5:1161-1175. [PMID: 36589694 PMCID: PMC9799247 DOI: 10.1002/jac5.1699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/29/2022] [Indexed: 01/05/2023]
Abstract
The vast majority of patients possess one or more pharmacogenetic variants that can influence optimal medication use. When pharmacogenetic data are used to guide drug choice and dosing, evidence points to improved disease outcomes, fewer adverse effects, and lower healthcare spending. Although its science is well established, clinical use of pharmacogenetic data to guide drug therapy is still in its infancy. Pharmacogenetics essentially involves the intersection of an individual's genetic data with their medications, which makes pharmacists uniquely qualified to provide clinical support and education in this field. In fact, most pharmacogenetics implementations, to date, have been led by pharmacists as leaders or members of a multidisciplinary team or as individual practitioners. A successful large-scale pharmacogenetics implementation requires coordination and synergy among administrators, clinicians, informatics teams, laboratories, and patients. Because clinical implementation of pharmacogenetics is in its early stages, there is an urgent need for guidance and dissemination of shared experiences to provide a framework for clinicians. Many early adopters of pharmacogenetics have explored various strategies among diverse practice settings. This article relies on the experiences of early adopters to provide guidance for critical steps along the pathway to implementation, including strategies to engage stakeholders; evaluate pharmacogenetic evidence; coordinate laboratory testing, results interpretation and their integration into the electronic health record; identify reimbursement avenues; educate providers and patients; and maintain a successful program. Learning from early adopters' published experiences and strategies can allow clinicians leading a new pharmacogenetics implementation to avoid pitfalls and adapt and apply lessons learned by others to their own practice.
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Affiliation(s)
- Emily J Cicali
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Fl, USA
| | - Lauren Lemke
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Fl, USA
| | - Hana Al Alshaykh
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Fl, USA
| | - Khoa Nguyen
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Fl, USA
| | - Kristin Wiisanen
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Fl, USA
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Haidar CE, Crews KR, Hoffman JM, Relling MV, Caudle KE. Advancing Pharmacogenomics from Single-Gene to Preemptive Testing. Annu Rev Genomics Hum Genet 2022; 23:449-473. [PMID: 35537468 PMCID: PMC9483991 DOI: 10.1146/annurev-genom-111621-102737] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pharmacogenomic testing can be an effective tool to enhance medication safety and efficacy. Pharmacogenomically actionable medications are widely used, and approximately 90-95% of individuals have an actionable genotype for at least one pharmacogene. For pharmacogenomic testing to have the greatest impact on medication safety and clinical care, genetic information should be made available at the time of prescribing (preemptive testing). However, the use of preemptive pharmacogenomic testing is associated with some logistical concerns, such as consistent reimbursement, processes for reporting preemptive results over an individual's lifetime, and result portability. Lessons can be learned from institutions that have implemented preemptive pharmacogenomic testing. In this review, we discuss the rationale and best practices for implementing pharmacogenomics preemptively.
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Affiliation(s)
- Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
| | - Kristine R Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
| | - James M Hoffman
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
- Office of Quality and Safety, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
| | - Kelly E Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
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Luczak T, Brown SJ, Armbruster D, Hundertmark M, Brown J, Stenehjem D. Strategies and settings of clinical pharmacogenetic implementation: a scoping review of pharmacogenetics programs. Pharmacogenomics 2021; 22:345-364. [PMID: 33829852 DOI: 10.2217/pgs-2020-0181] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pharmacogenetic (PGx) literature has shown beneficial outcomes in safety, efficacy and cost when evidence-based gene-drug decision making is incorporated into clinical practice. PGx programs with successfully implemented clinical services have been published in a variety of settings including academic health centers and community practice. The primary objective was to systematically scope the literature to characterize the current trends, extent, range and nature of clinical PGx programs. Forty articles representing 19 clinical PGx programs were included in analysis. Most programs are in urban, academic institutions. Education, governance and workflow were commonly described while billing/reimbursement and consent were not. This review provides an overview of current PGx models that can be used as a reference for institutions beginning the implementation process.
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Affiliation(s)
- Tiana Luczak
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA.,Essentia Health, Duluth, MN 55805, USA
| | - Sarah Jane Brown
- Health Sciences Libraries, University of Minnesota, MN 55455, USA
| | - Danielle Armbruster
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
| | - Megan Hundertmark
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
| | - Jacob Brown
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
| | - David Stenehjem
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN 55812, USA
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Establishment of a Pharmacogenetics Service Focused on Optimizing Existing Pharmacogenetic Testing at a Large Academic Health Center. J Pers Med 2020; 10:jpm10040154. [PMID: 33023029 PMCID: PMC7711716 DOI: 10.3390/jpm10040154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 01/20/2023] Open
Abstract
Multiple groups have described strategies for clinical implementation of pharmacogenetics (PGx) that often include internal laboratory tests that are specifically developed for their implementation needs. However, many institutions are not able to follow this practice and instead must utilize external laboratories to obtain PGx testing results. As each external laboratory might have different ordering and reporting workflows, consistent reporting and storing of PGx results within the medical record can be a challenge. This might result in patient safety concerns as important PGx information might not be easily identifiable at the point of current or future prescribing. Herein, we describe initial PGx clinical implementation efforts at a large academic medical center, focusing on optimizing three different test ordering workflows and two distinct result reporting strategies. From this, we identified common issues such as variable reporting location and structure of PGx results, as well as duplicate PGx testing. We identified several opportunities to optimize our current processes, including—(1) PGx laboratory stewardship, (2) increasing visibility of PGx tests, and (3) clinician and patient education. Key to the success was the importance of engaging clinician, informatics, and pathology stakeholders, as we developed interventions to improve our PGX implementation processes.
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Lee CR, Thomas CD, Beitelshees AL, Tuteja S, Empey PE, Lee JC, Limdi NA, Duarte JD, Skaar TC, Chen Y, Cook KJ, Coons JC, Dillon C, Franchi F, Giri J, Gong Y, Kreutz RP, McDonough CW, Stevenson JM, Weck KE, Angiolillo DJ, Johnson JA, Stouffer GA, Cavallari LH. Impact of the CYP2C19*17 Allele on Outcomes in Patients Receiving Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2020; 109:705-715. [PMID: 32897581 DOI: 10.1002/cpt.2039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/18/2020] [Indexed: 01/03/2023]
Abstract
Genotyping for CYP2C19 no function alleles to guide antiplatelet therapy after percutaneous coronary intervention (PCI) improves clinical outcomes. Although results for the increased function CYP2C19*17 allele are also reported, its clinical relevance in this setting remains unclear. A collaboration across nine sites examined antiplatelet therapy prescribing and clinical outcomes in 3,342 patients after implementation of CYP2C19-guided antiplatelet therapy. Risk of major atherothrombotic and bleeding events over 12 months after PCI were compared across cytochrome P450 2C19 isozyme (CYP2C19) metabolizer phenotype and antiplatelet therapy groups by proportional hazards regression. Clopidogrel was prescribed to a similar proportion of CYP2C19 normal (84.5%), rapid (82.9%), and ultrarapid metabolizers (80.6%) (P = 0.360). Clopidogrel-treated normal metabolizers (20.4 events/100 patient-years; adjusted hazard ratio (HR) 1.00, 95% confidence interval (CI), 0.75-1.33, P = 0.993) and clopidogrel-treated rapid or ultrarapid metabolizers (19.1 events/100 patient-years; adjusted HR 0.95, 95% CI, 0.69-1.30, P = 0.734) exhibited no difference in major atherothrombotic events compared with patients treated with prasugrel or ticagrelor (17.6 events/100 patient-years). In contrast, clopidogrel-treated intermediate and poor metabolizers exhibited significantly higher atherothrombotic event risk compared with prasugrel/ticagrelor-treated patients (adjusted HR 1.56, 95% CI, 1.12-2.16, P = 0.008). When comparing clopidogrel-treated rapid or ultrarapid metabolizers to normal metabolizers, no difference in atherothrombotic (adjusted HR 0.97, 95% CI, 0.73-1.29, P = 0.808) or bleeding events (adjusted HR 1.34, 95% CI, 0.83-2.17, P = 0.224) were observed. In a real-world setting of genotype-guided antiplatelet therapy, the CYP2C19*17 allele did not significantly impact post-PCI prescribing decisions or clinical outcomes. These results suggest the CYP2C19 *1/*17 and *17/*17 genotypes have limited clinical utility to guide antiplatelet therapy after PCI.
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Affiliation(s)
- Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip E Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nita A Limdi
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yiqing Chen
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James C Coons
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chrisly Dillon
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James M Stevenson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen E Weck
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
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Duong BQ, Arwood MJ, Hicks JK, Beitelshees AL, Franchi F, Houder JT, Limdi NA, Cook KJ, Owusu Obeng A, Petry N, Tuteja S, Elsey AR, Cavallari LH, Wiisanen K. Development of Customizable Implementation Guides to Support Clinical Adoption of Pharmacogenomics: Experiences of the Implementing GeNomics In pracTicE (IGNITE) Network. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:217-226. [PMID: 32765043 PMCID: PMC7373415 DOI: 10.2147/pgpm.s241599] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022]
Abstract
Introduction Clinical adoption of genomic medicine has lagged behind the pace of scientific discovery. Practice-based resources can help overcome implementation challenges. Methods In 2015, the IGNITE (Implementing GeNomics In pracTicE) Network created an online genomic medicine implementation resource toolbox that was expanded in 2017 to incorporate the ability for users to create targeted implementation guides. This expansion was led by a multidisciplinary team that developed an evidence-based, structured framework for the guides, oversaw the technical process/build, and pilot tested the first guide, CYP2C19-Clopidogrel Testing Implementation. Results Sixty-five resources were collected from 12 institutions and categorized according to a seven-step implementation framework for the pilot CYP2C19-Clopidogrel Testing Implementation Guide. Five months after its launch, 96 CYP2C19-Clopidogrel Testing Implementation Guides had been created. Eighty percent of the resources most frequently selected by users were created by IGNITE to fill an identified resource gap. Resources most often included in guides were from the test reimbursement (22%), Implementation support gathering (22%), EHR integration (17%), and genetic testing workflow steps (17%). Conclusion Lessons learned from this implementation guide development process provide insight for prioritizing development of future resources and support the value of collaborative efforts to create resources for genomic medicine implementation.
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Affiliation(s)
- Benjamin Q Duong
- Department of Precision Medicine, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Meghan J Arwood
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL, USA
| | - Amber L Beitelshees
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Francesco Franchi
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - John T Houder
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Nita A Limdi
- University of Alabama School at Birmingham, Birmingham, AL, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Jacksonville, FL, USA.,Department of Precision Medicine, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Natasha Petry
- Department of Pharmacy Practice, North Dakota State University College of Health Professions, Fargo, ND, USA
| | - Sony Tuteja
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Kristin Wiisanen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
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Cost-effectiveness of CYP2C19-guided antiplatelet therapy in patients with acute coronary syndrome and percutaneous coronary intervention informed by real-world data. THE PHARMACOGENOMICS JOURNAL 2020; 20:724-735. [PMID: 32042096 DOI: 10.1038/s41397-020-0162-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/25/2020] [Accepted: 01/29/2020] [Indexed: 12/25/2022]
Abstract
Current guidelines recommend dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 inhibitors following percutaneous coronary intervention (PCI). CYP2C19 genotype can guide DAPT selection, prescribing ticagrelor or prasugrel for loss-of-function (LOF) allele carriers (genotype-guided escalation). Cost-effectiveness analyses (CEA) are traditionally grounded in clinical trial data. We conduct a CEA using real-world data using a 1-year decision-analytic model comparing primary strategies: universal empiric clopidogrel (base case), universal ticagrelor, and genotype-guided escalation. We also explore secondary strategies commonly implemented in practice, wherein all patients are prescribed ticagrelor for 30 days post PCI. After 30 days, all patients are switched to clopidogrel irrespective of genotype (nonguided de-escalation) or to clopidogrel only if patients do not harbor an LOF allele (genotype-guided de-escalation). Compared with universal clopidogrel, both universal ticagrelor and genotype-guided escalation were superior with improvement in quality-adjusted life years (QALY's). Only genotype-guided escalation was cost-effective ($42,365/QALY) and demonstrated the highest probability of being cost-effective across conventional willingness-to-pay thresholds. In the secondary analysis, compared with the nonguided de-escalation strategy, although genotype-guided de-escalation and universal ticagrelor were more effective, with ICER of $188,680/QALY and $678,215/QALY, respectively, they were not cost-effective. CYP2C19 genotype-guided antiplatelet prescribing is cost-effective compared with either universal clopidogrel or universal ticagrelor using real-world implementation data. The secondary analysis suggests genotype-guided and nonguided de-escalation may be viable strategies, needing further evaluation.
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Davis BH, DeFrank G, Limdi NA, Harada S. Validation of the Spartan RXCYP2C19 Genotyping Assay Utilizing Blood Samples. Clin Transl Sci 2019; 13:260-264. [PMID: 31664775 PMCID: PMC7070822 DOI: 10.1111/cts.12714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/27/2019] [Indexed: 12/14/2022] Open
Abstract
The antiplatelet agent clopidogrel, a prodrug that requires bioactivation through the cytochrome P450 2C19 (CYP2C19) enzyme, is commonly prescribed post-percutaneous coronary intervention (PCI). Genetic variation in CYP2C19 contributes to individual variability in clopidogrel response, and can lead to adverse cardiovascular events. Incorporating CYP2C19 testing during routine clinical care helps identify high-risk patients, and provides the opportunity for pharmacotherapeutic interventions in the early post-PCI period. The Spartan RX CYP2C19 System has emerged as an optimal genotyping assay for use in clinical care due to ease of use, utilization of buccal swabs, and rapid turnaround time. However, workflow constraints related to sample collection and processing, storage, time, and personnel were encountered when integrating testing into clinical care. To improve clinical workflow and successfully implement CYP2C19 genotyping at our institution, we validated the Spartan RX System to return genotype utilizing blood samples. Our Molecular Diagnostic Laboratory tested 26 known reference materials and both blood and buccal swab samples from 23 patients and volunteers using the Spartan RX Assay. Genotype results were 100% concordant between DNA from blood and buccal swabs for all patients or volunteers, and consistent with expected results for the 26 reference materials. For reproducibility, three samples were tested in at least four separate runs, with all resulting genotypes in agreement between runs. Post-validation, the laboratory began offering CYP2C19 testing during clinical care. DNA extracted from blood can serve as a genomic DNA source for the Spartan RX Assay. Alteration of the methodology allowed for clinical implementation to support genotype-guided therapy.
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Affiliation(s)
- Brittney H Davis
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gina DeFrank
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nita A Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shuko Harada
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Grizzle WE. Issues in the Use of Human Tissues to Support Precision Medicine. J Health Care Poor Underserved 2019; 30:66-78. [PMID: 31735720 DOI: 10.1353/hpu.2019.0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Precision medicine is an approach in which the characteristics of patients as well as their diseases are used to identify optimal therapy; it links researchers, patients, health care providers, and clinical laboratories. In precision medicine, specific molecular characteristics of an untreatable cancer can be targeted by specific molecular-based therapy. Access to high-quality human tissues is necessary to determine many characteristics of patients and their diseases (such as targetable molecules). There are ethical issues in using human tissues in precision medicine, including informed consent and confidentiality, optimal utilization, quality of tissues, and minimization of bias. When human tissues are obtained for patient therapy, the bioresource should be a component certified by Clinical Laboratory Improvement Amendments. For precision medicine to benefit medically underserved populations requires extensive focused research, planning, and resources, some of which are currently unavailable at rural and other sites where care is provided to underserved populations.
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Truong TM, Lipschultz E, Danahey K, Schierer E, Ratain MJ, O'Donnell PH. Assessment of Patient Knowledge and Perceptions of Pharmacogenomics Before and After Using a Mock Results Patient Web Portal. Clin Transl Sci 2019; 13:78-87. [PMID: 31490020 PMCID: PMC6951853 DOI: 10.1111/cts.12681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/03/2019] [Indexed: 01/28/2023] Open
Abstract
Our objective was to build a mock pharmacogenomic (PGx) patient portal and assess its ability to disseminate test results and information to patients. The YourPGx Portal delivered four sample PGx results (omeprazole, simvastatin, clopidogrel, and codeine). We hosted two study groups to assess patient knowledge and perceptions of PGx before and after accessing the portal. Ten PGx‐tested and 10 traditional care participants were included (average 61 years, 60% women, 50% African American, and 55% had a bachelor's/advanced degree). Participants scored significantly higher on the post‐test compared with the pre‐test, with no significant differences between baseline scores or score change between the groups. Patient perceptions also improved after accessing the portal—more patients wanted their providers to have access to test results, and more patients would encourage family/friends to get PGx testing. Patients would share their test results with their healthcare providers, spouse/partner, and family; none would share results with their friends or social media. Almost all patients (95%) said the portal was easy to use and 65% said it was easy to understand. In this pilot study, patients’ knowledge and perceptions of PGx improved after accessing the YourPGx Portal.
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Affiliation(s)
- Tien M Truong
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA.,Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | - Elizabeth Lipschultz
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA.,Center for Research Informatics, The University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA.,Center for Research Informatics, The University of Chicago, Chicago, Illinois, USA
| | - Emily Schierer
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | - Mark J Ratain
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA.,Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA.,Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA.,Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA.,Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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12
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Fitzgerald G, Prince C, Downing J, Reynolds J, Zhang JE, Hanson A, Alfirevic A, Pirmohamed M. Processes and barriers to implementation of point-of-care genotype-guided dosing of warfarin into UK outpatient anticoagulation clinics. Pharmacogenomics 2019; 20:599-608. [DOI: 10.2217/pgs-2019-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Gail Fitzgerald
- Research Nurse, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Clare Prince
- Research Nurse, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Jennifer Downing
- Research Manager, NIHR CLAHRC NWC, University of Liverpool, Liverpool, UK
| | - Julia Reynolds
- Associate Director, Innovation Agency, Academic Health Science Network for the North West Coast, Warrington, UK
| | - Jieying Eunice Zhang
- Post-doctoral Research Associate, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Anita Hanson
- Research Nurse, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Ana Alfirevic
- Professor of Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- David Weatherall Chair of Medicine, University of Liverpool & Royal Liverpool & Broadgreen University Hospitals NHS Trust, Liverpool, UK
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13
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14
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Empey PE, Stevenson JM, Tuteja S, Weitzel KW, Angiolillo DJ, Beitelshees AL, Coons JC, Duarte JD, Franchi F, Jeng LJ, Johnson JA, Kreutz RP, Limdi NA, Maloney KA, Obeng AO, Peterson JF, Petry N, Pratt VM, Rollini F, Scott SA, Skaar TC, Vesely MR, Stouffer GA, Wilke RA, Cavallari LH, Lee CR. Multisite Investigation of Strategies for the Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy. Clin Pharmacol Ther 2018; 104:664-674. [PMID: 29280137 PMCID: PMC6019555 DOI: 10.1002/cpt.1006] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/27/2017] [Accepted: 12/20/2017] [Indexed: 01/05/2023]
Abstract
CYP2C19 genotype-guided antiplatelet therapy following percutaneous coronary intervention is increasingly implemented in clinical practice. However, challenges such as selecting a testing platform, communicating test results, building clinical decision support processes, providing patient and provider education, and integrating methods to support the translation of emerging evidence to clinical practice are barriers to broad adoption. In this report, we compare and contrast implementation strategies of 12 early adopters, describing solutions to common problems and initial performance metrics for each program. Key differences between programs included the test result turnaround time and timing of therapy changes, which are both related to the CYP2C19 testing model and platform used. Sites reported the need for new informatics infrastructure, expert clinicians such as pharmacists to interpret results, physician champions, and ongoing education. Consensus lessons learned are presented to provide a path forward for those seeking to implement similar clinical pharmacogenomics programs within their institutions.
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Affiliation(s)
- Philip E. Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Sony Tuteja
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kristin W. Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Dominick J. Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - James C. Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Julio D. Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Linda J.B. Jeng
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham AL
| | - Kristin A. Maloney
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai; and Pharmacy Department, The Mount Sinai Hospital, New York, NY
| | - Josh F. Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha Petry
- Department of Pharmacy Practice, North Dakota State University, Fargo, ND
| | - Victoria M. Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Fabiana Rollini
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Stuart A. Scott
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY and Sema4, a Mount Sinai venture, Stamford, CT
| | - Todd C. Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - George A. Stouffer
- Division of Cardiology, School of Medicine and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Russell A. Wilke
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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15
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Cavallari LH, Franchi F, Rollini F, Been L, Rivas A, Agarwal M, Smith DM, Newsom K, Gong Y, Elsey AR, Starostik P, Johnson JA, Angiolillo DJ. Clinical implementation of rapid CYP2C19 genotyping to guide antiplatelet therapy after percutaneous coronary intervention. J Transl Med 2018; 16:92. [PMID: 29642909 PMCID: PMC5896099 DOI: 10.1186/s12967-018-1469-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/31/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The CYP2C19 nonfunctional genotype reduces clopidogrel effectiveness after percutaneous coronary intervention (PCI). Following clinical implementation of CYP2C19 genotyping at University Florida (UF) Health Shands Hospital in 2012, where genotype results are available approximately 3 days after PCI, testing was expanded to UF Health Jacksonville in 2016 utilizing a rapid genotyping approach. We describe metrics with this latter implementation. METHODS Patients at UF Health Jacksonville undergoing left heart catheterization with intent to undergo PCI were targeted for genotyping using the Spartan RX™ system. Testing metrics and provider acceptance of testing and response to genotype results were examined, as was antiplatelet therapy over the 6 months following genotyping. RESULTS In the first year, 931 patients, including 392/505 (78%) total patients undergoing PCI, were genotyped. The median genotype test turnaround time was 96 min. Genotype results were available for 388 (99%) PCI patients prior to discharge. Of 336 genotyped PCI patients alive at discharge and not enrolled in an antiplatelet therapy trial, 1/6 (17%) poor metabolizers (PMs, with two nonfunctional alleles), 38/93 (41%) intermediate metabolizers (IMs, with one nonfunctional allele), and 119/237 (50%) patients without a nonfunctional allele were prescribed clopidogrel (p = 0.110). Clopidogrel use was higher among non-ACS versus ACS patients (78.6% vs. 42.2%, p < 0.001). Six months later, among patients with follow-up data, clopidogrel was prescribed in 0/4 (0%) PMs, 33/65 (51%) IMs, and 115/182 (63%) patients without a nonfunctional allele (p = 0.008 across groups; p = 0.020 for PMs versus those without a nonfunctional allele). CONCLUSION These data demonstrate that rapid genotyping is clinically feasible at a high volume cardiac catheterization facility and allows informed chronic antiplatelet prescribing, with lower clopidogrel use in PMs at 6 months. Trial registration ClinicalTrials.gov Identifier: NCT02724319; registered March 31, 2016; https://www.clinicaltrials.gov/ct2/show/NCT02724319?term=angiolillo&rank=7.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Fabiana Rollini
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Latonya Been
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Andrea Rivas
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Malhar Agarwal
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - D. Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
| | - Kimberly Newsom
- University of Florida Health Pathology Laboratories, Gainesville, FL USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
| | - Amanda R. Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL USA
| | - Petr Starostik
- University of Florida Health Pathology Laboratories, Gainesville, FL USA
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL USA
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
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16
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Kiss ÁF, Vaskó D, Déri MT, Tóth K, Monostory K. Combination of CYP2C19 genotype with non-genetic factors evoking phenoconversion improves phenotype prediction. Pharmacol Rep 2017; 70:525-532. [PMID: 29665549 DOI: 10.1016/j.pharep.2017.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/29/2017] [Accepted: 12/01/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND CYP2C19 is an important drug-metabolizing enzyme, responsible for metabolism of approximately 10% of the drugs on the market. Large inter-individual differences exist in metabolic activities, which are primarily attributed to genetic polymorphism of CYP2C19 gene. Conflicting results have been published about the role of CYP2C19 polymorphisms in metabolism of CYP2C19 substrates and clinical outcomes; thus, we aimed to investigate CYP2C19 genotype-phenotype associations, and we sought to elicit potential causes of discrepancies in the genotype-based prediction by incorporating the liver donors' demographic data, drug administration events and pathological conditions. METHODS (S)-Mephenytoin was used to assess CYP2C19 activities in human liver microsomes derived from 114 Hungarian organ donors. CYP2C19 genotype was determined by SNP genotyping for CYP2C19*2, CYP2C19*3, CYP2C19*4 and CYP2C19*17 variants, and CYP2C19 mRNA levels were measured by qPCR method. Clinical data of the donors were considered in the genotype-based phenotype prediction. RESULTS CYP2C19 phenotype of 40% of the donors was well-predicted from the genotype data, whereas the phenotype of 13% was underestimated displaying higher activity, and of 47% was overestimated displaying lower activity than predicted from CYP2C19 genotype. Among the donors with overestimated phenotype, one was treated with CYP2C19 substrate/inhibitor, 9 were on amoxicillin-clavulanic acid therapy, 7 were chronic alcohol consumers and 9 had disease with inflammatory processes. CONCLUSIONS CYP2C19 genotype only partially determines the CYP2C19 phenotypic appearance; co-medication, diseases with inflammatory processes and aspecific factors, such as chronic alcohol consumption and amoxicillin-clavulanic acid therapy (or any drug therapy resulting in liver injury) seem to be potential phenotype-modifying factors.
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Affiliation(s)
- Ádám Ferenc Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Dorottya Vaskó
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Máté Tamás Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary.
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17
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Haga SB. Integrating pharmacogenetic testing into primary care. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017; 2:327-336. [PMID: 31853504 DOI: 10.1080/23808993.2017.1398046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction Pharmacogenetic (PGx) testing has greatly expanded due to enhanced understanding of the role of genes in drug response and advances in DNA-based testing technology development. As many primary care visits result in a prescription, the use of PGx testing may be particularly beneficial in this setting. However, integration of PGx testing may be limited as no uniform approach to delivery of tests has been established and providers are ill-prepared to integrate PGx testing into routine care. Areas covered In this paper, the readiness of primary care practitioners are reviewed as well as strategies to address these barriers based on published research and ongoing activities on education and implementation of PGx testing. Expert Commentary Widespread integration of PGx testing will warrant continued education and point-of-care decisional support. Primary care providers may also benefit from consultation services or team-based care with laboratory medicine specialists, pharmacists, and genetic counselors.
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Affiliation(s)
- Susanne B Haga
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 304 Research Drive, Durham, NC 27708, USA,
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18
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Cavallari LH. Personalizing antiplatelet prescribing using genetics for patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2017; 15:581-589. [PMID: 28699807 DOI: 10.1080/14779072.2017.1355236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Clopidogrel is commonly prescribed with aspirin to reduce the risk for adverse cardiovascular events after percutaneous coronary intervention (PCI). However, there is significant inter-patient variability in clopidogrel response. The CYP2C19 enzyme is involved in the biotransformation of clopidogrel to its pharmacologically active form, and variation in the CYP2C19 gene contributes to clopidogrel response variability. Areas covered. This article describes the impact of CYP2C19 genotype on clopidogrel pharmacokinetics, pharmacodynamics, and effectiveness. Examples of clinical implementation of CYP2C19 genotype-guided antiplatelet therapy for patients undergoing PCI are also described as are emerging outcomes data with this treatment approach. Expert commentary. A large clinical trial evaluating outcomes with CYP2C19 genotype-guided antiplatelet therapy after PCI is on-going. In the meantime, data from pragmatic and observational studies and smaller trials support improved outcomes with genotyping after PCI and use of alternative antiplatelet therapy in patients with a CYP2C19 genotype associated with reduced clopidogrel effectiveness.
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Affiliation(s)
- Larisa H Cavallari
- a Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics , University of Florida College of Pharmacy , Gainesville , FL , USA
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