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Pharmacogenetics . Simplified
How Effective are Medications?
How Can I Know What & How Much to Prescribe?
Order a Pharmacogentics (PGx) test.
Who is Already Using (or teaching)
PGx Testing?• Harvard Medical School & Beth Israel Deaconess• Vanderbilt• Georgetown Medical School• Stanford University - Center for Genomics and Personalized Medicine
• Scripps-Howard• Columbia Presbyterian• Weill Cornell Precision Medical Institute• NIH & FDA• Drug Manufactures – Tailored Therapeutics• Cardiology & Anesthesiology Boards
Benefits of PGx Testing
Right Drug at the Right Dose for the Right Patientfor the First Time!
• Precision prescribing is better medicine than “Trial and Error Prescribing.”
• Decrease ADE’s (adverse drug events)
• Less hospitalizations as a result of ADE’s• Healthcare cost savings
What is Pharmacogenetics (PGx)?
It is the study of Genetic Differences in Metabolic Pathways which can affect Individual Responses to drugs, both in terms of therapeutic affect as well as adverse effects (how genetics influence a patient’s response to medications).
What is Pharmacogenetics (PGx)?
•Genes affect Patient Drug Metabolism and Response•Predict in Advance = Better Medicine/Outcomes•Genomic Differences
▫Influence Efficacy – Therapeutic Window▫Increase Risk of serious Drug Side Effects▫Increase risk of Drug-Drug Interaction
Personalized Medicine Adds Precision to Prescribing•Tailoring Medical Treatment to Individual Patient•Sophisticated Molecular Tools•Better Outcomes with Fewer Adverse Events•Personal Medicine is a shift from what works for a
“typical” patient to what works for the “Individual” patient.
•Right Drug for the Right Patient at the Right Dose
The Future is PGx Testing
“The point of personalized medicine is to develop better efficacy, better outcomes, fewer adverse affects and lower systemic costs.”
Dr. Edward Abrahams Personalized Medicine Coalition – The Boston GlobeJanuary 25, 2010
Why Utilize PGx Testing?• Identify likelihood of Adverse Drug Event (ADE)
▫ 25-50% have polymorphism▫ 2.2 Million ADE’s occur annually with 106,000 deaths
• Increase Drug Efficacy▫ Only 58% of Pain Management Patients receive Relief▫ Cardiac patients with Reduced Function Alleles have 3.5 – 8
times greater risk for major CV Event▫ 30% of Psychiatric disorders have severe ADE’s▫ 50% of Urology drugs have No Therapeutic Affect
• Increase Patient Compliance and Retention• Standard of Care – Specialty Boards• Market Practice, Mitigate Risk, Reduce Healthcare Costs
PGx Dynamics
Patient’s Genetic Profile
Metabolizer Phenotype
Drug Type
Active Drugs Prodrugs
Poor Metabolizer (PM)
Reduced Elimination
Increased Toxicity Risk
Decreased Effectiveness
Decreased Activation
Intermediate Metabolizer (IM)
Increased Drug-to-Gene and Drug-t0-Drug Interaction Risk
Possible Increased Toxicity Risk
Normal/Extensive Metabolizer (NM,EM)
Performs according to FDA label specifications
Rapid or Ultra Rapid Metabolizer (RM,URM)
Reduced Effectiveness
Increased Elimination
Increased Activation
Increased Toxicity Risk
Reports: Simple & InformativeCARDIAC PHARMACOGENTIC MARKERS
Drug Gene Result Implications
Therapeutic Recommendations
Clopidogrel
Plavix®
CYP2C19
*1/*1Normal
metabolizer
Normal Metabolizer of Clopidogrel
*Start Clopidogrel at 300 mg (loading dose) and continue with 75 mg daily (maintenance dose).*Avoid using Clopidogrel with Omeprazole, a CYP2C19 inhibitor.
Warfarin(Coumadi
n®)
CYP2C9
VKORC1
*1/*1 *B/*BNormal
metabolizerLow
Sensitivity
Normal inhibition of vitamin K reductase
*Consider 5-7 mg/day to achieve therapeutic INR using the Warfarin product insert approved by the USFDA. Additonal information at www.warfarindosing.org.
Beta Blockers Propranol
ol (Inderal
®)
CYP2D6 *1/*41
Normal metaboliz
er
Normal Metabolism of Beta Blockers
*Consider Drug Label-Recommended Dosage and Administration
Ticagrelor
CYP3A4
CYP3A5
*1/*1B, *1/*3
Intermediate
metabolizer
Intermediate Metabolism of Ticagretor
*Consider Ticagrelor Label Recommended Dosage and Administration*Avoid use with Potent CYP3A Inducers (see Table 3 of CYP3A Report)*Avoid us of Strong Inhibitors of CYP3A (see Table 3 of CYP3A Report)
Cardiac & Pain Panels
Plavix* (Clopidogrel bisulfate) Factor II
B-Blockers Factor V Leiden
Warfarin MTHFR
APO-E
Codeine Methadone
Hydrocodone Meperidine
Oxycodone Buprenorphine
Fentanyl Sufentanil
Psychiatric & Urology Panels
PSYCHIATRIC MEDICATION
UROLOGYMEDICATION
Alprazolam Fluvoxamine
Amitriptyline Haloperidol
Aripriprazole Mirtazapine
Atomoxetine Nortriptyline
Buspirone Olanzapine
Citalopram Paroxetine
Clomipramine Pimozide
Clonazepam Quetiapine
Diazepam Risperidone
Doxepin Sertraline
Duloxetine Trazodone
Escitalopram Venlafaxine
Fluoxetine Ziprasidone
Benign Prostatic Hyperplasia (BPH) Drugs
Terazosin (Hytrin) Silodosin (Rapaflo*)
Doxazosin (Cardura) Dutasteride (Avodart)
Alfuzosin (Uroxatral) Dutasteride/Tamsulosin (Jalyn)
Tamsulosin (Flomax) Finasteride (Proscar)
Overactive Bladder
Oxybutynin (Ditropan*) Trospium (Sanctura*)
Solifenacin (Vesicare) Tolteradine (Detrol*)
Darifenacin (Enablex*) Fesoterodine fumarate (Toviaz)
Erectile Dysfunction
Sildenafil (Viagra*) Tadalafil (Cialis*)
Vardenafil (Levitra*)
Tailored Therapeutics
“The power in tailored therapeutics is for us to say more clearly to payers, providers, and patients – ‘this drug is not for everyone, but it is for you.’ That is exceedingly powerful.”
John C. Lechleiter, Ph.DPresident and Chief Executive Officer, Eli Lilly and Company
Goals
“Today, one of our biggest goals is to cut the cost of sequencing an entire human genome to $1,000 or less. This advance will pave the way for each person’s genome to be sequenced as part of the standard of care, leading to a revolution in the practice of medicine.”
Francis S. Collins, M.D., Ph.D.Director, National Institute of Health
Implement PGx in Your Practice•Buccal Swabs - Simple, Non-invasive, Quick, Convenient
•No Costs - Test Kit & On-site Pickup free to practice
• Clinically Actionable Results – Easy to Read & Electronically Delivered
• Insurance Paid – Covered by Medicare & most major Commercial Payers
•New Revenue Source - Physician Reimbursed for Interpretation
•Pharm-D - Available for Consultation
