genetics and primary care: a research agenda leigh lopresti, m.d. waukesha family medicine residency...
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Genetics and Primary Care:A Research Agenda
Leigh LoPresti, M.D.
Waukesha Family Medicine Residency Program
Medical College of Wisconsin
November 12, 2009
Why Me?
• Family Physician Full-time practice for 15 years after
residency Mostly rural
• Transition to academics was genetics driven
• Lucky in genetics
Primary Care
• “A primary care physician is a generalist physician who…takes continuing responsibility for providing the patient's care…for substantially all of the patient's medical and health care needs - not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.”
• We: Diagnose Treat Prevent Care for multiple family members
Genetics
• “Medical geneticists are health professionals who are dedicated to using and interpreting genetic information to maintain and improve the health of individuals, their families and communities.”
• They: Diagnose Treat Care for multiple family members
Genetics Progress
• Old Well-Known News:
Human Genome Project 1990-2003 Sequenced genome, found MANY
fewer genes than expected Purpose of large parts of genome
unknown Identified 1.8 million SNP’s
Genetics Progress
• Not Well-Known News:HapMap Project 2002-ongoing Identified larger sections of DNA that cn be
identified by a single SNP: a haplotype Characterized haplotype variability in 3
populations in Phases 1-2. Now Phase 3: 11 populations, 1100+
individuals Basis for current GWAS studies
Genetics Progress
• Ongoing Work GWAS studies Cancer Genome Project Human Microbiome Project Pharmacogenomics RNA interference
GWAS
• Associations between genes and disease OFTEN unexpected associations Requires very low p values due to more
associations being looked for We are looking for genes of at most
moderate effect (RR 1.4-2.0, most commonly)
They can still be important in disease by being commonly found alleles
Published Genome-Wide Associations through
Published Genome-Wide Associations439 published GWA at p < 5 x 10-8
NHGRI GWA Catalogwww.genome.gov/GWAStudies
Cancer Genome
• Cancer is a disease of DNA!• Goal is to define the differences between
a cancer cell and normal cells• 2007-2010 for pilot project• Working so far with glioblastoma, lung
(squamous cell), and ovarian cancers• Next up: 20 more, most types
undetermined, but will include breast and renal cell
Microbiology
• Pathogens
• Some bacteria (MRSA) are now identified genetically in hours
• Most have now been sequenced and proteomics and expression profiling are at least promising new targets for drugs and vaccines.
Microbiome
• The Human Microbiome Project 2008 to present (planned end 2013?) Now working to understand:
Composition Communities Roles
of our commensal (mutualistic?) organisms and how they change in
Health Disease, and with medical treatments
Microbiome
• Estimates 1000 species 1013 organisms 1.5 kg of bacteria
• Significant variation across people: may only be about a 1% match across people
}in GI tract alone
Microbiome
• Current areas of suspected involvement— Obesity (lactobacillus protective?)
— Colorectal Cancer (lactobacillus protective?)
— Inflammatory Bowel Disease— Irritable Bowel Syndrome— Alcoholic Encephalopathy (lactobacillus protective?)
— Fibromyalgia— Sepsis Syndrome
Journal of Leukocyte Biology 2008. 83: 461-466.
Pharmacogenetics
• Early well established examples TPMT Her-2
• Emerging Areas Warfarin CYP2C19 for Plavix (clopidogrel)
• Other areas Drug Interactions: omeprazole,
fluoxetine
RNA Interference
• Discovered in 1998 (Nobel Prize, 2006)
• Two types of small RNA molecules siRNA: double stranded RNA 21-23 bp
Transcription inhibition; miRNA: single stranded RNA, 20-25 bp
Translation inhibitionTargets mRNAs for destruction
• Highly conserved in evolution: present from C. elegans to humans
RNA Interference
• Both might be used in therapeutics 580 articles in last three years on human RNAi
therapeutics
• Current therapeutic targets under investigation (#1) Infectious Diseases
Hepatitis CHIV-1RSV
Oncology (cancer is a disease of DNA)
RNA Interference
• Therapeutic targets under investigation (#2) Common Diseases
Type 2 diabetesHypercholesterolemiaRheumatoid Arthritis
Neurologic DiseasesParkinson’s DiseaseAmyotrophic lateral sclerosisHuntington Disease
Genetics and Primary Care I
• Diagnosis Newborn Screening
State testing is expanding, now up to 48 disorders in Wisconsin
Includes genetic diseases with early effect—Sickle cell—Cystic Fibrosis
Genetic Diseases with later effectsHemochromatosis or α-1 antitrypsinBRCA and Lynch Syndrome
Genetics and Primary Care II
• Diagnosis in the future Microbiology
Early diagnosis of organisms and sensitivities?
Pre-morbid risks Obesity Type 2 DM Macular degeneration
Genetics and Primary Care III
• Treatment: Pharmacogenetics Activation of Drugs
Clopidogrel (CYP2C19) Tamoxifen (CYP2D6)
Metabolism of drugs TPMT Warfarin
Receptors for Drugs Warfarin
Genetics and Primary Care IV
Primary and Secondary Prevention
Nothing
Yet
A Research Agenda
• What we won’t do Discover new genes Link genes to diseases (GWAS) Link genes to treatment issues Make discoveries in proteomics
A Research Agenda
• What we can be involved with Practice studies of pharmacogenetics
UnderwayWarfarinPsych drugs
To come?Hypertension, Diabetes, and Asthma drugs
Microbiology and microbiome issuesShorten hospital stays based on early and
accurate microbiologic diagnosis?Effects (short- and long-term) on and recovery
of microbiome after treatments
A Research Agenda
• Where we can LEAD! Provider education
Interpreting Direct to Consumer (DTC) studies
Work with the DTC companies proactively
Point-of-care resources for community practitioners
Expanding list of genetic diseases and influences
A Research Agenda
• Where we can LEAD! EHR’s and family history
Again, proactive contact with corporationsWorking with structured data Importing from other sources (Surgeon General)Computerized decision support
Are these measures more effective for patients and providers?
EHR’s and other issuesPharmacogeneticsLoading and using genomes or DTC findings
A Research Agenda
A Research Agenda
• Where we can LEAD! Primary prevention
Type 2 Diabetes mellitusMost important gene is TCF7L2; first
associated 2006—Allele frequency 22-29% (several close mutations
known) in general population—Stunningly consistent results (different populations)—A few papers show interaction with obesity
measures—Unknown interactions with other genes, metabolic
syndrome, age, gender, lab values—Mechanism unknown
From BMC Medical Genetics 2009, 10:15
A Research Agenda
A Research Agenda
• Where we can LEAD! Primary prevention
Alcohol and Drug AbuseRisks for alcohol abuse, nicotine abuse, other drug
abuse, and “externalizing” psych conditions all somewhat related in inheritance
Heritability of alcohol abuse in 50-60% range; at least 15 possible genes
No GWAS as yet!Possible pharmacogenetics predicting response to
naltrexoneGenetic harm? Less likely to quit if genetically
programmed?BRCA, Lynch and other cancer syndromes
A Research Agenda
• Where we can LEAD! “Secondary” prevention
What do genetic predispositions MEAN?Using GWAS data in prospective trials
—TCF7L2: minimum of 1500 people needed; more if looking at other variables as well
Gene-Environment interactionsWhat patient education/other interventions make a
difference?BRCA and breast/ovarian cancer preventionTCF7L2
Does premorbid pharmacologic treatment change outcomes?
Is it cost-effective?
A Research Agenda
• Where we can LEAD! More secondary prevention
As a consequence of any of the above, can we avoid secondary co-morbidities (diabetes on hypertension?)
Does use of pharmacogenomics in practice reduce adverse drug reactions and decrease costs?
A Call to Action?
• Genetics is well suited to primary care
• There are studies that can be best done in large systems that some of us work in
• We are the experts in what will work in “real” practices
• There are many untouched places that we can lead…