1
|
Yazbeck A, Akika R, Awada Z, Zgheib NK. Pharmacogenetic considerations in therapy with novel antiplatelet and anticoagulant agents. Pharmacogenet Genomics 2024; 34:61-72. [PMID: 38372412 DOI: 10.1097/fpc.0000000000000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Antiplatelets and anticoagulants are extensively used in cardiovascular medicine for the prevention and treatment of thrombosis in the venous and arterial circulations. Wide inter-individual variability has been observed in response to antiplatelets and anticoagulants, which triggered researchers to investigate the genetic basis of this variability. Data from extensive pharmacogenetic studies pointed to strong evidence of association between polymorphisms in candidate genes and the pharmacokinetics and pharmacodynamic action and clinical response of the antiplatelets clopidogrel and the anticoagulant warfarin. In this review, we conducted an extensive search on Medline for the time period of 2009-2023. We also searched the PharmGKB website for levels of evidence of variant-drug combinations and for drug labels and clinical guidelines. We focus on the pharmacogenetics of novel antiplatelets and anticoagulants while excluding acetylsalicylic acid, warfarin and heparins, and discuss the current knowledge with emphasis on the level of evidence.
Collapse
Affiliation(s)
| | - Reem Akika
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Zainab Awada
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nathalie K Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
2
|
Lim KK, Koleva‐Kolarova R, Kamaruzaman HF, Kamil AA, Chowienczyk P, Wolfe CDA, Fox‐Rushby J. Genetic-Guided Pharmacotherapy for Coronary Artery Disease: A Systematic and Critical Review of Economic Evaluations. J Am Heart Assoc 2024; 13:e030058. [PMID: 38390792 PMCID: PMC10944053 DOI: 10.1161/jaha.123.030058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/15/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Genetic-guided pharmacotherapy (PGx) is not recommended in clinical guidelines for coronary artery disease (CAD). We aimed to examine the extent and quality of evidence from economic evaluations of PGx in CAD and to identify variables influential in changing conclusions on cost-effectiveness. METHODS AND RESULTS From systematic searches across 6 databases, 2 independent reviewers screened, included, and rated the methodological quality of economic evaluations of PGx testing to guide pharmacotherapy for patients with CAD. Of 35 economic evaluations included, most were model-based cost-utility analyses alone, or alongside cost-effectiveness analyses of PGx testing to stratify patients into antiplatelets (25/35), statins (2/35), pain killers (1/35), or angiotensin-converting enzyme inhibitors (1/35) to predict CAD risk (8/35) or to determine the coumadin doses (1/35). To stratify patients into antiplatelets (96/151 comparisons with complete findings of PGx versus non-PGx), PGx was more effective and more costly than non-PGx clopidogrel (28/43) but less costly than non-PGx prasugrel (10/15) and less costly and less effective than non-PGx ticagrelor (22/25). To predict CAD risk (51/151 comparisons), PGx using genetic risk scores was more effective and less costly than clinical risk score (13/17) but more costly than no risk score (16/19) or no treatment (9/9). The remaining comparisons were too few to observe any trend. Mortality risk was the most common variable (47/294) changing conclusions. CONCLUSIONS Economic evaluations to date found PGx to stratify patients with CAD into antiplatelets or to predict CAD risk to be cost-effective, but findings varied based on the non-PGx comparators, underscoring the importance of considering local practice in deciding whether to adopt PGx.
Collapse
Affiliation(s)
- Ka Keat Lim
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
| | - Rositsa Koleva‐Kolarova
- Health Economics Research Centre, Nuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
| | - Hanin Farhana Kamaruzaman
- Health Economics and Health Technology Assessment (HEHTA), School of Health and WellbeingUniversity of GlasgowGlasgowUnited Kingdom
- Malaysian Health Technology Assessment Section (MaHTAS), Medical Development Division, Ministry of HealthPutrajayaMalaysia
| | - Ahmad Amir Kamil
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
| | - Phil Chowienczyk
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
- King’s College London British Heart Foundation CentreSt. Thomas’ Hospital, Westminster BridgeLondonUnited Kingdom
| | - Charles D. A. Wolfe
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC), South LondonLondonUnited Kingdom
| | - Julia Fox‐Rushby
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
| |
Collapse
|
3
|
Fragoulakis V, Koufaki MI, Tzerefou K, Koufou K, Patrinos GP, Mitropoulou C. Assessing the utility of measurement methods applied in economic evaluations of pharmacogenomics applications. Pharmacogenomics 2024; 25:79-95. [PMID: 38288576 DOI: 10.2217/pgs-2023-0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
An increasing number of economic evaluations are published annually investigating the economic effectiveness of pharmacogenomic (PGx) testing. This work was designed to provide a comprehensive summary of the available utility methods used in cost-effectiveness/cost-utility analysis studies of PGx interventions. A comprehensive review was conducted to identify economic analysis studies using a utility valuation method for PGx testing. A total of 82 studies met the inclusion criteria. A majority of studies were from the USA and used the EuroQol-5D questionnaire, as the utility valuation method. Cardiovascular disorders was the most studied therapeutic area while discrete-choice studies mainly focused on patients' willingness to undergo PGx testing. Future research in applying other methodologies in PGx economic evaluation studies would improve the current research environment and provide better results.
Collapse
Affiliation(s)
| | - Margarita-Ioanna Koufaki
- University of Patras, School of Health Sciences, Department of Pharmacy, Laboratory of Pharmacogenomics & Individualized Therapy, 26504, Rio, Patras, Greece
| | - Korina Tzerefou
- University of Piraeus, Economics Department, 18534, Piraeus, Greece
| | | | - George P Patrinos
- University of Patras, School of Health Sciences, Department of Pharmacy, Laboratory of Pharmacogenomics & Individualized Therapy, 26504, Rio, Patras, Greece
- United Arab Emirates University, College of Medicine & Health Sciences, Department of Genetics & Genomics, P.O. Box. 15551, Al-Ain, Abu Dhabi, United Arab Emirates
- United Arab Emirates University, Zayed Center for Health Sciences, P.O. Box. 15551, Al-Ain, Abu Dhabi, United Arab Emirates
| | - Christina Mitropoulou
- The Golden Helix Foundation, London, SE1 8RT, UK
- United Arab Emirates University, Zayed Center for Health Sciences, P.O. Box. 15551, Al-Ain, Abu Dhabi, United Arab Emirates
| |
Collapse
|
4
|
Morris SA, Alsaidi AT, Verbyla A, Cruz A, Macfarlane C, Bauer J, Patel JN. Cost Effectiveness of Pharmacogenetic Testing for Drugs with Clinical Pharmacogenetics Implementation Consortium (CPIC) Guidelines: A Systematic Review. Clin Pharmacol Ther 2022; 112:1318-1328. [PMID: 36149409 PMCID: PMC9828439 DOI: 10.1002/cpt.2754] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/17/2022] [Indexed: 01/31/2023]
Abstract
The objective of this study was to evaluate the evidence on cost-effectiveness of pharmacogenetic (PGx)-guided treatment for drugs with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. A systematic review was conducted using multiple biomedical literature databases from inception to June 2021. Full articles comparing PGx-guided with nonguided treatment were included for data extraction. Quality of Health Economic Studies (QHES) was used to assess robustness of each study (0-100). Data are reported using descriptive statistics. Of 108 studies evaluating 39 drugs, 77 (71%) showed PGx testing was cost-effective (CE) (N = 48) or cost-saving (CS) (N = 29); 21 (20%) were not CE; 10 (9%) were uncertain. Clopidogrel had the most articles (N = 23), of which 22 demonstrated CE or CS, followed by warfarin (N = 16), of which 7 demonstrated CE or CS. Of 26 studies evaluating human leukocyte antigen (HLA) testing for abacavir (N = 8), allopurinol (N = 10), or carbamazepine/phenytoin (N = 8), 15 demonstrated CE or CS. Nine of 11 antidepressant articles demonstrated CE or CS. The median QHES score reflected high-quality studies (91; range 48-100). Most studies evaluating cost-effectiveness favored PGx testing. Limited data exist on cost-effectiveness of preemptive and multigene testing across disease states.
Collapse
Affiliation(s)
- Sarah A. Morris
- Department of Cancer Pharmacology and PharmacogenomicsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | | | - Allison Verbyla
- Health Economics and Outcomes Research, Department of BiostatisticsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | - Adilen Cruz
- Health Economics and Outcomes Research, Department of BiostatisticsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | | | - Joseph Bauer
- Health Economics and Outcomes Research, Department of BiostatisticsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | - Jai N. Patel
- Department of Cancer Pharmacology and PharmacogenomicsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| |
Collapse
|
5
|
Mugosa S, Radosavljevic I, Sahman M, Djordjevic N, Todorovic Z. Risk factors for adverse drug reactions associated with clopidogrel therapy. Open Med (Wars) 2022; 17:694-701. [PMID: 35480401 PMCID: PMC8990878 DOI: 10.1515/med-2021-0371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 08/20/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Abstract
This study aimed to investigate the possible influence of genetic and non-genetic factors on the incidence of clopidogrel adverse drug reactions (ADRs) in cardiology patients, including the most important CYP2C19 alleles, namely *2 and *17, as well as compliance, dose, drug interactions, and clinical factors. A total of 102 clopidogrel-treated adult Caucasian patients hospitalized at the Cardiology Department of the Clinical Center of Montenegro were enrolled in the study. Data on clinical outcomes of interest were obtained by intensive monitoring ADRs during hospitalization and one year after hospital discharge. Genotyping for CYP2C19*2 and *17 was conducted using the real-time polymerase chain reaction method. ADRs were characterized using the Rawlins and Thompson classification and the World Health Organization criteria. Causality was assessed using the Naranjo probability scale. ADRs to clopidogrel were observed in 9 of 102 patients (8.8%). The observed frequencies of CYP2C19*2 and *17 were 13.2 and 25.5%, respectively. Our study, which is the first to report the frequency of CYP2C19 polymorphism in the Montenegrin population, as well as to link the pharmacovigilance of clopidogrel with CYP2C19 gene variability, shows that the incidence of ADRs of clopidogrel in cardiac patients is high and depends on CYP2C19 polymorphisms, comedication/drug interactions, and gastrointestinal comorbidity.
Collapse
Affiliation(s)
- Snezana Mugosa
- Department of Pharmacology, Faculty of Medicine, University of Montenegro , 81000 Podgorica , Montenegro
- Clinical Trials Department, Institute for Medicines and Medical Devices of Montenegro , 81000 Podgorica , Montenegro
| | - Ivan Radosavljevic
- Department of Surgery, Faculty of Medical Sciences, University of Kragujevac , 34000 Kragujevac , Serbia
| | - Majda Sahman
- Department of Pharmacology, Faculty of Medicine, University of Montenegro , 81000 Podgorica , Montenegro
- Clinical Trials Department, Institute for Medicines and Medical Devices of Montenegro , 81000 Podgorica , Montenegro
| | - Natasa Djordjevic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac , 34000 Kragujevac , Serbia
| | - Zoran Todorovic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade , Belgrade , Serbia
- University Medical Center “Bežanijska kosa” , Belgrade , Serbia
| |
Collapse
|
6
|
V Aswathy SP, Chandra KR, Jyothikrishna P, Arun KP. Dosage optimization of clopidogrel via a precision medicine approach: the way forward. Pharmacogenomics 2022; 23:195-206. [PMID: 35112572 DOI: 10.2217/pgs-2020-0198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Clopidogrel is a prodrug chiefly metabolized by the hepatic isoenzyme CYP2C19 to its active metabolite that inhibits the platelet aggregation. It has been proven in many populations that the genetic polymorphism of CYP2C19 has influence on the pharmacokinetic and or pharmacodynamics of this drug and resulting in high inter-individual variability in the treatment outcomes. As CYP2C19 genetic polymorphism is highly prevalent among the Asian population, the influence of the same on the pharmacokinetics and; thereby, the pharmacodynamics of clopidogrel needs more attention. Using the pharmacogenetic information for drug therapy could help overcome these issues and to optimize the dosage regimen of clopidogrel, this review advocates the precision medicine approach for reducing the clopidogrel resistance and adverse cardiovascular events.
Collapse
Affiliation(s)
- Sasidharan Pillai V Aswathy
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, The Nilgiris, Ooty, Tamil Nadu, 643001, India
| | - Kotha Rohith Chandra
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, The Nilgiris, Ooty, Tamil Nadu, 643001, India
| | - Pakkath Jyothikrishna
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, The Nilgiris, Ooty, Tamil Nadu, 643001, India
| | - Kanniappan Parthasarathy Arun
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, The Nilgiris, Ooty, Tamil Nadu, 643001, India
| |
Collapse
|
7
|
Turongkaravee S, Jittikoon J, Rochanathimoke O, Boyd K, Wu O, Chaikledkaew U. Pharmacogenetic testing for adverse drug reaction prevention: systematic review of economic evaluations and the appraisal of quality matters for clinical practice and implementation. BMC Health Serv Res 2021; 21:1042. [PMID: 34600523 PMCID: PMC8487501 DOI: 10.1186/s12913-021-07025-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/14/2021] [Indexed: 12/21/2022] Open
Abstract
Background Genetic testing has potential roles in identifying whether an individual would have risk of adverse drug reactions (ADRs) from a particular medicine. Robust cost-effectiveness results on genetic testing would be useful for clinical practice and policy decision-making on allocating resources effectively. This study aimed to update a systematic review on economic evaluations of pharmacogenetic testing to prevent ADRs and critically appraise the quality of reporting and sources of evidence for model input parameters. Methods We searched studies through Medline via PubMed, Scopus and CRD’s NHS Economic Evaluation up to October 2019. Studies investigating polymorphism-based pharmacogenetic testing, which guided drug therapies to prevent ADRs, using economic evaluation methods were included. Two reviewers independently performed data extraction and assessed the quality of reporting using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines and the quality of data sources using the hierarchy of evidence developed by Cooper et al. Results Fifty-nine economic evaluations of pharmacogenetic testing to avoid drug-induced ADRs were found between 2002 and 2018. Cost-utility and cost-effectiveness analyses were the most common methods of economic evaluation of pharmacogenetic testing. Most studies complied with the CHEERS checklist, except for single study-based economic evaluations which did not report uncertainty analysis (78%). There was a lack of high-quality evidence not only for estimating the clinical effectiveness of pharmacogenetic testing, but also baseline clinical data. About 14% of the studies obtained clinical effectiveness data of testing from a meta-analysis of case-control studies with direct comparison, which was not listed in the hierarchy of evidence used. Conclusions Our review suggested that future single study-based economic evaluations of pharmacogenetic testing should report uncertainty analysis, as this could significantly affect the robustness of economic evaluation results. A specific ranking system for the quality of evidence is needed for the economic evaluation of pharmacogenetic testing of ADRs. Differences in parameters, methods and outcomes across studies, as well as population-level and system-level differences, may lead to the difficulty of comparing cost-effectiveness results across countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07025-8.
Collapse
Affiliation(s)
- Saowalak Turongkaravee
- Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Jiraphun Jittikoon
- Department of Biochemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Onwipa Rochanathimoke
- Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Kathleen Boyd
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Usa Chaikledkaew
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayuthaya Rd, Payathai, Ratchathewi, Bangkok, 10400, Thailand. .,Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
8
|
Narasimhalu K, Ang YK, Tan DSY, De Silva DA, Tan KB. Cost Effectiveness of Genotype-Guided Antiplatelet Therapy in Asian Ischemic Stroke Patients: Ticagrelor as an Alternative to Clopidogrel in Patients with CYP2C19 Loss of Function Mutations. Clin Drug Investig 2020; 40:1063-1070. [PMID: 32959334 DOI: 10.1007/s40261-020-00970-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with ischemic stroke are often treated with clopidogrel monotherapy as part of secondary stroke prevention. The prevalence of loss of function (LOF) mutations in the CYP2C19 gene is higher in Asians than in Western populations. Patients with loss of function (LOF) mutations are at risk for poorer secondary outcomes when prescribed clopidogrel. OBJECTIVE We aimed to determine the cost effectiveness of genotype-guided antiplatelet therapy in an Asian population with the aim of prescribing ticagrelor as an alternative to patients with LOF mutations. METHODS Markov models were developed to look at the cost effectiveness of genetic testing of CYP2C19, with patients who screened positive for LOF alleles being switched to ticagrelor compared to universal clopidogrel treatment. Effect ratios were obtained from the literature and incidence rates and costs were obtained from the national data published by the Singapore Ministry of Health. Lifetime costs and quality-adjusted life-years (QALYs) were calculated. The primary endpoints were the incremental cost-effectiveness ratios (ICERs). RESULTS The prevalence of the LOF mutations was 61% in the population, with 65% of ethnic Chinese, 60% of ethnic Indian, and 53% of ethnic Malay patients having LOF mutations. Based on this prevalence, the overall ICER of genetic testing was S$33,839/QALY with ICERS of S$30,755/QALY, S$33,177/QALY, and S$41,470/QALY for Chinese, Indians, and Malays, respectively. CONCLUSION This study suggests that it is cost effective to screen for LOF mutations in the CYP2C19 gene in ischemic stroke populations, with ticagrelor as a substitute for clopidogrel in those with LOF mutations.
Collapse
Affiliation(s)
- Kaavya Narasimhalu
- Department of Neurology (SGH Campus), National Neuroscience Institute, Outram Road, 169608, Singapore, Singapore.
| | - Yoong Kwei Ang
- Policy, Research and Evaluation Division, Ministry of Health, Singapore, Singapore
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Doreen Su Yin Tan
- Policy, Research and Evaluation Division, Ministry of Health, Singapore, Singapore
- Khoo Teck Puat Hospital, Singapore, Singapore
| | - Deidre Anne De Silva
- Department of Neurology (SGH Campus), National Neuroscience Institute, Outram Road, 169608, Singapore, Singapore
| | - Kelvin Bryan Tan
- Policy, Research and Evaluation Division, Ministry of Health, Singapore, Singapore
- School of Public Health, National University of Singapore, Singapore, Singapore
| |
Collapse
|
9
|
Fatunde OA, Brown SA. The Role of CYP450 Drug Metabolism in Precision Cardio-Oncology. Int J Mol Sci 2020; 21:E604. [PMID: 31963461 PMCID: PMC7014347 DOI: 10.3390/ijms21020604] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 12/13/2022] Open
Abstract
As many novel cancer therapies continue to emerge, the field of Cardio-Oncology (or onco-cardiology) has become crucial to prevent, monitor and treat cancer therapy-related cardiovascular toxicity. Furthermore, given the narrow therapeutic window of most cancer therapies, drug-drug interactions are prevalent in the cancer population. Consequently, there is an increased risk of affecting drug efficacy or predisposing individual patients to adverse side effects. Here we review the role of cytochrome P450 (CYP450) enzymes in the field of Cardio-Oncology. We highlight the importance of cardiac medications in preventive Cardio-Oncology for high-risk patients or in the management of cardiotoxicities during or following cancer treatment. Common interactions between Oncology and Cardiology drugs are catalogued, emphasizing the impact of differential metabolism of each substrate drug on unpredictable drug bioavailability and consequent inter-individual variability in treatment response or development of cardiovascular toxicity. This inter-individual variability in bioavailability and subsequent response can be further enhanced by genomic variants in CYP450, or by modifications of CYP450 gene, RNA or protein expression or function in various 'omics' related to precision medicine. Thus, we advocate for an individualized approach to each patient by a multidisciplinary team with clinical pharmacists evaluating a treatment plan tailored to a practice of precision Cardio-Oncology. This review may increase awareness of these key concepts in the rapidly evolving field of Cardio-Oncology.
Collapse
Affiliation(s)
- Olubadewa A. Fatunde
- Department of Medicine, University of Texas Health Science Center at Tyler–CHRISTUS Good Shepherd Medical Center, Longview, TX 75601, USA
| | - Sherry-Ann Brown
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
10
|
Kasztura M, Richard A, Bempong NE, Loncar D, Flahault A. Cost-effectiveness of precision medicine: a scoping review. Int J Public Health 2019; 64:1261-1271. [PMID: 31650223 PMCID: PMC6867980 DOI: 10.1007/s00038-019-01298-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/19/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Objectives Precision medicine (PM) aims to improve patient outcomes by stratifying or individualizing diagnosis and treatment decisions. Previous reviews found inconclusive evidence as to the cost-effectiveness of PM. The purpose of this scoping review was to describe current research findings on the cost-effectiveness of PM and to identify characteristics of cost-effective interventions.
Methods We searched PubMed with a combination of terms related to PM and economic evaluations and included studies published between 2014 and 2017.
Results A total of 83 articles were included, of which two-thirds were published in Europe and the USA. The majority of studies concluded that the PM intervention was at least cost-effective compared to usual care. However, the willingness-to-pay thresholds varied widely. Key factors influencing cost-effectiveness included the prevalence of the genetic condition in the target population, costs of genetic testing and companion treatment and the probability of complications or mortality. Conclusions This review may help inform decisions about reimbursement, research and development of PM interventions. Electronic supplementary material The online version of this article (10.1007/s00038-019-01298-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Miriam Kasztura
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.
| | - Aude Richard
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nefti-Eboni Bempong
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dejan Loncar
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
11
|
Zhu Y, Swanson KM, Rojas RL, Wang Z, St Sauver JL, Visscher SL, Prokop LJ, Bielinski SJ, Wang L, Weinshilboum R, Borah BJ. Systematic review of the evidence on the cost-effectiveness of pharmacogenomics-guided treatment for cardiovascular diseases. Genet Med 2019; 22:475-486. [PMID: 31591509 PMCID: PMC7056639 DOI: 10.1038/s41436-019-0667-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/23/2019] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To examine the evidence on the cost-effectiveness of implementing pharmacogenomics (PGx) in cardiovascular disease (CVD) care. METHODS We conducted a systematic review using multiple databases from inception to 2018. The titles and abstracts of cost-effectiveness studies on PGx-guided treatment in CVD care were screened, and full texts were extracted. RESULTS We screened 909 studies and included 46 to synthesize. Acute coronary syndrome and atrial fibrillation were the predominantly studied conditions (59%). Most studies (78%) examined warfarin-CYP2C9/VKORC1 or clopidogrel-CYP2C19. A payer's perspective was commonly used (39%) for cost calculations, and most studies (46%) were US-based. The majority (67%) of the studies found PGx testing to be cost-effective in CVD care, but cost-effectiveness varied across drugs and conditions. Two studies examined PGx panel testing, of which one examined pre-emptive testing strategies. CONCLUSION We found mixed evidence on the cost-effectiveness of PGx in CVD care. Supportive evidence exists for clopidogrel-CYP2C19 and warfarin-CYP2C9/VKORC1, but evidence is limited in other drug-gene combinations. Gaps persist, including unclear explanation of perspective and cost inputs, underreporting of study design elements critical to economic evaluations, and limited examination of PGx panel and pre-emptive testing for their cost-effectiveness. This review identifies the need for further research on economic evaluations of PGx implementation.
Collapse
Affiliation(s)
- Ye Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kristi M Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ricardo L Rojas
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L St Sauver
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Liewei Wang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Richard Weinshilboum
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA. .,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
12
|
Cost-Effectiveness of Strategies to Personalize the Selection of P2Y12 Inhibitors in Patients with Acute Coronary Syndrome. Cardiovasc Drugs Ther 2019; 33:533-546. [DOI: 10.1007/s10557-019-06896-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
13
|
Alviggi C, Conforti A, Santi D, Esteves SC, Andersen CY, Humaidan P, Chiodini P, De Placido G, Simoni M. Clinical relevance of genetic variants of gonadotrophins and their receptors in controlled ovarian stimulation: a systematic review and meta-analysis. Hum Reprod Update 2019; 24:599-614. [PMID: 29924306 DOI: 10.1093/humupd/dmy019] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/12/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Genotype has been implicated in the outcome of ovarian stimulation. The analysis of patient-specific genotypes might lead to an individualized pharmacogenomic approach to controlled ovarian stimulation (COS). However, the validity of such an approach remains to be established. OBJECTIVE AND RATIONALE To define the impact of specific genotype profiles of follicle-stimulating hormone, luteinizing hormone and their receptors (FSHR, LHR and LHCGR) on ovarian stimulation outcome. Specifically, our aim was to identify polymorphisms that could be useful in clinical practice, and those that need further clinical investigation. SEARCH METHODS A systematic review followed by a meta-analysis was performed according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines without time restriction. We searched the PubMed/MEDLINE, Cochrane Library, SCOPUS and EMBASE databases to identify all relevant studies published before January 2017. Only clinical trials published as full-text articles in peer-reviewed journals were included. The primary outcome was the number of oocytes retrieved. OUTCOMES Fifty-seven studies were assessed for eligibility, 33 of which were included in the qualitative and quantitative analyses. Data were independently extracted using quality indicators. COS outcomes related to seven polymorphisms (FSHR [rs6165], FSHR [rs6166], FSHR [rs1394205], LHB [rs1800447], LHB [rs1056917], LHCGR [rs2293275] and LHCGR [rs13405728]) were evaluated. More oocytes were retrieved from FSHR (rs6165) AA homozygotes (five studies, 677 patients, weighted mean difference [WMD]: 1.85, 95% CI: 0.85-2.85, P < 0.001; I2 = 0%) than from GG homozygotes and AG heterozygotes (four studies, 630 patients, WMD: 1.62, 95% CI: 0.28-2.95, P = 0.020; I2 = 56%). Moreover, stimulation duration was shorter in FSHR (rs6165) AA homozygotes than in AG carriers (three studies, 588 patients, WMD -0.48, 95% CI: -0.87 to -0.10, P = 0.010, I2 = 44%). A higher number of oocytes (21 studies, 2632 patients WMD: 0.84, 95% CI: 0.19 to 1.49, P = 0.01, I2 = 76%) and metaphase II oocytes (five studies, 608 patients, WMD: 1.03, 95% CI: 0.01-2.05, P = 0.050, I2 = 0%) was observed in AA than in GG homozygote carriers. FSH consumption was significantly lower in FSHR (rs1394205) GG homozygotes (three studies, 411 patients, WMD: -1294.61 IU, 95% CI: -593.08 to -1996.14 IU, P = 0.0003, I2 = 99%) and AG heterozygotes (three studies, 367 patients, WMD: -1014.36 IU, 95% CI: -364.11 to -1664.61 IU, P = 0.002, I2 = 99%) than in AA homozygotes. WIDER IMPLICATIONS These results support the clinical relevance of specific genotype profiles on reproductive outcome. Further studies are required to determine their application in a pharmacogenomic approach to ovarian stimulation.
Collapse
Affiliation(s)
- Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Italy.,Istituto per l'Endocrinologia e l'Oncologia Sperimentale, Consiglio Nazionale delle Ricerche, Napoli, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Italy
| | - Daniele Santi
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, and Azienda Ospedaliera-Universitaria di Modena, Italy
| | - Sandro C Esteves
- Androfert, Andrology and Human Reproduction Clinic, and Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Italy
| | - Manuela Simoni
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, and Azienda Ospedaliera-Universitaria di Modena, Italy
| |
Collapse
|
14
|
Borse MS, Dong OM, Polasek MJ, Farley JF, Stouffer GA, Lee CR. CYP2C19-guided antiplatelet therapy: a cost-effectiveness analysis of 30-day and 1-year outcomes following percutaneous coronary intervention. Pharmacogenomics 2017; 18:1155-1166. [PMID: 28745582 DOI: 10.2217/pgs-2017-0075] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AIM Determine whether using CYP2C19 genotype to optimize antiplatelet therapy selection is cost effective over the initial 30 days and 1-year following percutaneous coronary intervention. MATERIALS & METHODS A cost-effectiveness analysis compared 30-day and 1-year outcomes and cost across three treatment strategies (universal clopidogrel, universal prasugrel, genotype-guided) in a hypothetical cohort. RESULTS Base-case scenario results at 30 days indicated that the incremental cost per major cardiovascular or bleeding event avoided for genotype-guided treatment was US$8525 and US$42,198 compared with universal clopidogrel and prasugrel, respectively. Probabilistic sensitivity analysis demonstrated that genotype-guided treatment was cost effective over 30 days and 1 year in 62 and 70% of simulations, respectively. CONCLUSION Implementing a CYP2C19 genotype-guided approach to antiplatelet therapy could have a positive economic impact by preventing readmissions following percutaneous coronary intervention.
Collapse
Affiliation(s)
- Mrudula S Borse
- Division of Pharmaceutical Outcomes & Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Olivia M Dong
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,UNC Center for Pharmacogenomics & Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Melissa J Polasek
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Joel F Farley
- Division of Pharmaceutical Outcomes & Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - George A Stouffer
- UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,Division of Cardiology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Craig R Lee
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,UNC Center for Pharmacogenomics & Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| |
Collapse
|
15
|
Kim K, Lee TA, Touchette DR, DiDomenico RJ, Ardati AK, Walton SM. Contemporary Trends in Oral Antiplatelet Agent Use in Patients Treated with Percutaneous Coronary Intervention for Acute Coronary Syndrome. J Manag Care Spec Pharm 2017; 23:57-63. [PMID: 28025925 PMCID: PMC10398038 DOI: 10.18553/jmcp.2017.23.1.57] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent trials demonstrated the efficacy of prasugrel and ticagrelor compared with clopidogrel in the reduction of cardiovascular complications in patients with acute coronary syndrome (ACS). However, it is unclear how use of the 3 antiplatelet medications has changed in commercially insured patients since the advent of the new agents. OBJECTIVES To (a) describe the adoption of prasugrel and ticagrelor in patients who received percutaneous coronary intervention (PCI) for the onset of ACS and (b) explore patient factors associated with the selection of the drug to provide insight into utilization patterns of these antiplatelet agents. METHODS Patients who received a new dispensing of an antiplatelet agent following a hospitalization for a PCI administered for ACS were identified from insurance claims between 2009 and 2013. Demographics and comorbid conditions were determined based on a 6-month period before the ACS event. Longitudinal trends in antiplatelet agent selection were illustrated using descriptive statistics segmented by month and quarter. Using logistic regressions with stepwise model selection, factors associated with use of the newer medications, as well as with the selection between ticagrelor and prasugrel, were identified. RESULTS The analysis included 66,335 subjects. The use of clopidogrel decreased from 100% to roughly 65% of total antiplatelet agent use by the end of 2011 and leveled off thereafter. The introduction of ticagrelor in 2011 coincided with a drop in prasugrel initiation from 35%-18% by December 2013. The use of new agents as opposed to use of clopidogrel was associated with younger age (< 65 years), male gender, and a diagnosis of ST-elevation myocardial infarction. In addition, conditions increasing mortality and risk of cardiovascular complication were associated with higher odds of using clopidogrel. The odds of using ticagrelor over prasugrel increased with older age and history of a cerebrovascular event. CONCLUSIONS In 2013, clopidogrel remained the most prescribed agent. Meanwhile, ticagrelor had gradually replaced a substantial portion of prasugrel initiation. Further investigation into outcomes associated with the newer agents, as well as reasons behind the conservative use of the antiplatelet agents, is warranted. DISCLOSURES No funding was received for the conduct of this study. DiDomenico received an honorarium from Amgen for the preparation of a heart failure drug monograph for Pharmacy Practice News and was a co-investigator on funded research for the Patient-Centered Outcomes Research Institute. DiDomenico also serves as an advisory board member for a heart failure program at Otsuka America Pharmaceuticals and as an advisory board member at Novartis Pharmaceuticals. Touchette has received unrestricted grant funding from Cardinal Health and Sunovion Pharmaceuticals and has also served as a consultant to and director of the American College of Clinical Pharmacy Practice-Based Research Network on a study funded by Pfizer. None of the authors of this study are involved in financial or personal relationships with agencies, institutions, or organizations that inappropriately influenced the statistical analysis plan or interpretation of the results. Study concept and design were contributed by Kim, Lee, Touchette, and Walton, with assistance from DiDomenico and Ardati. Kim and Lee collected the data, and data interpretation was performed by Lee, DiDomenico, and Ardati, along with Kim and Walton and assisted by Touchette. The manuscript was written by Kim and Walton, with assistance from the other authors, and revised by Kim, Walton, and Lee, with assistance from the other authors.
Collapse
Affiliation(s)
- Kibum Kim
- 1 Pharmacotherapy Outcomes Research Center, and Department of Pathology, University of Utah, Salt Lake City
| | - Todd A Lee
- 2 Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
| | - Daniel R Touchette
- 2 Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
| | - Robert J DiDomenico
- 3 Center for Pharmacoepidemiology and Pharmacoeconomic Research, and Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago
| | - Amer K Ardati
- 4 Division of Cardiology, College of Medicine, University of Illinois at Chicago
| | - Surrey M Walton
- 2 Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
| |
Collapse
|
16
|
Mugoša S, Djordjević N, Bukumirić Z, Djukanović N, Cukić J, Radosavljević I, Baskić D, Protić D, Zdravković M, Todorović Z. PREDICT score and CYP2C19 polymorphism independently predict lack of efficacy of clopidogrel in cardiology patients. Clin Exp Pharmacol Physiol 2016; 43:379-81. [PMID: 26699839 DOI: 10.1111/1440-1681.12531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Snežana Mugoša
- Faculty of Pharmacy, University of Montenegro, Podgorica, Montenegro
| | - Nataša Djordjević
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Zoran Bukumirić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | | | - Ivan Radosavljević
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Dejan Baskić
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Dragana Protić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Zdravković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Medical Center "Bežanijska kosa", Belgrade, Serbia
| | - Zoran Todorović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Medical Center "Bežanijska kosa", Belgrade, Serbia
| |
Collapse
|
17
|
Mitropoulou C, Fragoulakis V, Rakicevic LB, Novkovic MM, Vozikis A, Matic DM, Antonijevic NM, Radojkovic DP, van Schaik RH, Patrinos GP. Economic analysis of pharmacogenomic-guided clopidogrel treatment in Serbian patients with myocardial infarction undergoing primary percutaneous coronary intervention. Pharmacogenomics 2016; 17:1775-1784. [PMID: 27767438 DOI: 10.2217/pgs-2016-0052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Clopidogrel, which is activated by the CYP2C19 enzyme, is among the drugs for which all major regulatory agencies recommend genetic testing to be performed to identify a patient's CYP2C19 genotype in order to determine the optimal antiplatelet therapeutic scheme. The CYP2C19*2 and CYP2C19*3 variants are loss-of-function alleles, leading to abolished CYP2C19 function and thus have the risk of thrombotic events for carriers of these alleles on standard dosages, while the CYP2C19*17 allele results in CYP2C19 hyperactivity. AIMS Here, we report our findings from a retrospective study to assess whether genotyping for the CYP2C19*2 allele was cost effective for myocardial infarction patients receiving clopidogrel treatment in the Serbian population compared with the nongenotype-guided treatment. RESULTS We found that 59.3% of the CYP2C19*1/*1 patients had a minor or major bleeding event versus 42.85% of the CYP2C19*1/*2 and *2/*2, while a reinfarction event occurred only in 2.3% of the CYP21C9*1/*1 patients, compared with 11.2% of the CYP2C19*1/*2 and CYP2C19*2/*2 patients. There were subtle differences between the two patient groups, as far as the duration of hospitalization and rehabilitation is concerned, in favor of the CYP2C19*1/*1 group. The mean cost for the CYP2C19*1/*1 patients was estimated at €2547 versus €2799 in the CYP2C19*1/*2 and CYP2C19*2/*2 patients. Furthermore, based on the overall CYP2C19*1/*2 genotype frequencies in the Serbian population, a break-even point analysis indicated that performing the genetic test prior to drug prescription represents a cost-saving option, saving €13 per person on average. CONCLUSION Overall, our data demonstrate that pharmacogenomics-guided clopidogrel treatment may represent a cost-saving approach for the management of myocardial infarction patients undergoing primary percutaneous coronary intervention in Serbia.
Collapse
Affiliation(s)
- Christina Mitropoulou
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Vasilios Fragoulakis
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece.,National School of Public Health, Athens, Greece
| | - Ljiljana B Rakicevic
- Institute for Molecular Genetics & Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Mirjana M Novkovic
- Institute for Molecular Genetics & Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | | | - Dragan M Matic
- Emergency Department, Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Nebojsa M Antonijevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Dragica P Radojkovic
- Institute for Molecular Genetics & Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Ron H van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| |
Collapse
|
18
|
Christensen KD, Dukhovny D, Siebert U, Green RC. Assessing the Costs and Cost-Effectiveness of Genomic Sequencing. J Pers Med 2015; 5:470-86. [PMID: 26690481 PMCID: PMC4695866 DOI: 10.3390/jpm5040470] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/01/2015] [Accepted: 12/04/2015] [Indexed: 11/17/2022] Open
Abstract
Despite dramatic drops in DNA sequencing costs, concerns are great that the integration of genomic sequencing into clinical settings will drastically increase health care expenditures. This commentary presents an overview of what is known about the costs and cost-effectiveness of genomic sequencing. We discuss the cost of germline genomic sequencing, addressing factors that have facilitated the decrease in sequencing costs to date and anticipating the factors that will drive sequencing costs in the future. We then address the cost-effectiveness of diagnostic and pharmacogenomic applications of genomic sequencing, with an emphasis on the implications for secondary findings disclosure and the integration of genomic sequencing into general patient care. Throughout, we ground the discussion by describing efforts in the MedSeq Project, an ongoing randomized controlled clinical trial, to understand the costs and cost-effectiveness of integrating whole genome sequencing into cardiology and primary care settings.
Collapse
Affiliation(s)
- Kurt D Christensen
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA.
| | - Uwe Siebert
- Department of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol 6060, Austria.
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Robert C Green
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Partners Personalized Medicine, Boston, MA 02115, USA.
| |
Collapse
|