pharmacogenomics implementation: …...pharmacogenetics 5 there is significant interpatient...
TRANSCRIPT
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Houda Hachad, PharmD
PHARMACOGENOMICS IMPLEMENTATION: APPLICATION TO PEDIATRIC PATIENTS.
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Disclosures Active Employee and equity holder of Translational Software, a technology company that build products to allow implementation of genomic medicine to the clinic
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Outline Introduction to Pharmacogenetics
Clinical Pharmacogenetics (PGX) Programs
Inova’s MediMap Program
Pediatric Pharmacogenetics
What we have learned so far
Conclusions
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Active Areas of Precision Medicine Targeted therapies for cancer
Pharmacogenomics (PGx)
Diagnosis and screening for constitutional disorders
Rapid identification of pathogens
Nutrigenomics and wellness
The microbiome
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Pharmacogenetics
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There is significant interpatient variability in drug response which is largely attributed to innate differences among individuals in their capacity to process and react to drugs.
Pharmacogenomics (PGx)
Study how genetics can be used to inform therapeutic decisions
Main goals is to “end the therapeutic odyssey”, lower the burden of adverse drug events and improve treatment outcomes
Novel tool to add to existing medication optimization tools such as therapeutic drug monitoring, medication therapy management approaches
PGx knowledge uses principles from human genetics, pharmacokinetics and pharmacodynamics
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Issues revealed by PGx tests Inadequate exposure to active drug or metabolites
◦ Relates to Cytochrome P450 enzymes or transporters
◦ Linked to decreased or increased drug clearance associated with poor / fast metabolism or altered transporter function
◦ Metabolism phenotype range from poor (absent) to ultra-rapid (increased)
◦ Prodrug and active drug altered differently by metabolism phenotypes
Altered affinity of a drug for its target
◦ Altered expression of a drug target alters sensitivity to a drug
◦ Altered expression of a biological function
Idiosyncratic/immunological response
◦ Drug hypersensitivity reactions associated with HLA risk alleles
◦ Examples: Stevens-Johnson Syndrome and toxic epidermal necrolysis
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Examples of PGx applications Medication Gene - Type Issue Benefit
Codeine, Tramadol CYP2D6 (PK) Prodrug activation by CYP2D6
Loss of efficacy or increased toxicity Drug selection
Tricyclics, SSRIs CYP2C19 (PK) CYP2D6 (PK)
Inactivation of active drug by CYP2D6 and CYP2C19 Loss of efficacy or increased toxicity
Drug selection and dose optimization to avoid supra- or sub- therapeutic levels
Ondansetron CYP2D6 (PK) Inactivation of active drug by CYP2D6
Avoid loss of efficacy
Drug selection to avoid sub- therapeutic levels
Carbamazepine HLA-B*15:02 Hypersensitivity reaction in HLA risk allele carriers Drug selection
Warfarin CYP2C9 (PK) VKORC1 (PD)
Inactivation of active drug by CYP2C9-VKORC1 is warfarin target Decreased efficacy or increased toxicity
Adequate dosing requirements
Clopidogrel CYP2C19 – PK Prodrug activation by CYP2C19
Loss of efficacy or increased toxicity Drug selection
Thiopurines TPMT – PK Inactivation of active drug by TPMT
increased toxicity Dosing guidance to avoid toxicity
Atazanavir UGT1A1 - PK Inactivation of bilirubin by UGT1A1
Increased toxicity Drug selection
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Pharmaco genetic variability is multi-scalar
Single Gene and Single Variant
SLCO1B1 rs4149056 Simvastatin dosing
Single Gene and Multi- Variants
CYP2D6 rs16947 + rs3892097 + rs1065852
Opioids efficacy
Multi-Gene CYP2D6 + CYP2C19 Tricyclics, SSRIs dosing
Multi-Gene + other variables
CYP2C9 + VKORC1 + ethnicity
Warfarin dosing
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Consensus PGx Practice Guidelines
250 members from 30 countries
Experts from academia, hospitals, industry (FDA, NIH observers)
Practice guideline for 44 drug-genes pairs since 2010
In 2015 decision to consider pediatrics
https://cpicpgx.org/
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PGx in the clinic: current landscape
PGX programs implemented in 45 healthcare institutions
International Consortia of Experts: CPIC – U-PGx – EUPIC
Regulator involvement (PGx Info In label)
Profusion of testing technologies and instrument vendors
Documented effectiveness of selected programs
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Institutions implementing PGx programs
BJC Healthcare Group Health / University of
Washington NorthShore University
HealthSystem University of Extremadura
Boston Children's Hospital / Harvard Medical
I.M.P. Institute of Predictive Medicine
Ohio State University University of Florida Health
British Columbia Pharmacy Association
Icahn School of Medicine at Mount Sinai
Robert-Bosch Stiftung University of Malta
Children's Cancer Hospital of Egypt
Indiana University Sanford Health University of Maryland
Children's Hospital Minnesota Inova Women’s Hospital Seattle Children's Hospital University of North Carolina
Cincinnati Children's Hospital Medical Center
Leiden University Medical Center St. Jude Children's Hospital University of Pennsylvania
School of Medicine
Clearview Cancer Institute Mayo Clinic Stanford University University of Pittsburgh / UPMC Presbyterian University Hospital
Cleveland Clinic Medical College of Wisconsin University Hospital Schleswig-Holstein
University of South Florida
CVS Caremark/Generation Health Mission Health University of Alabama Vanderbilt University
Erasmus MC Moffitt Cancer Center & Research Institute
University of Chicago Veterans Affairs
Geisinger Health System National Institutes of Health
Clinical Center (NIH CC) University of Colorado Washington University in St. Louis
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Institution Starting Date Genes Medications Reported Clinical Workflow Integration Technology Used
Boston Children’s Hospital InforMED Kids
2012 TPMT CYP2C9 VKORC1
Thiopurines Warfarin
The patient is swabbed and genotyped. Some of the genetic information is stored on the electronic patient’s medical records. BPAs exist for TPMT, CYP2C9, & VKORC1
EPIC/Cerner Affymetrix DMET+
Cincinnati Children’s Hospital
CYP2D6 CYP2C9 VKORC1
Psychotropic: Tricyclics and SSRIs Opioids Phenytoin Warfarin
Patient receives and fills out the test requisition form from the doctor. Patient also provides blood or cheek swabs for the lab. A report is generated with dosing recommendations, and drug-drug interactions. Pharmacology consults are available
Epic
St. Jude Children’s PG4KDs
2011 CYP2C19 CYP2D6 CYP3A5 DPYD SLCO1B1 TPMT UGT1A1 [230 genes assayed]
Clopidogrel Voriconazole Psychotropic: Tricyclics and SSRIs Opioids Tacrolimus Simvastatin Atazanavir Belinostat Thiopurines Dihydropyrimidines
Available to all patients Patient is enrolled, genotyped. Genotypes are evaluated and recorded in the medical records. Specific genotypes will send out BPAs when the doctor tries to order certain medications
Cerner Affymetrix DMET+
Inova MediMap
2016 TPMT CYP2C9 VKORC1 CYP2C19 SLCO1B1 CYP2D6 CYP3A5
Clopidogrel Tricyclics SSRIs Codeine Phenytoin Tacrolimus Simvastatin Thiopurines Voriconazole Ondansetron
Available to patients of Inova Buccal swab of patient is collected following consent Test run in-house An interpretive report is generated by Translational Software and delivered by genetic counselors to the parents A one time report that lives in the EMR
Epic Ion Torrent
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Inova’s PGx
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Inova’s MediMap Baby • Offered to all newborns delivered at Inova Women’s Hospital and Inova Fair Oaks Hospital.
• Inova is the only health system in the U.S. that provides this optional PGx test to newborns free of charge as an optional part of the standard package of services.
•Multi disciplinary efforts between several partners
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https: https://www.inova.org/medimap/baby
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Inova’s MediMap Baby From a lab to the physician
Result
Files
Variant
Calls Type
Analysis Types
Meta-types
Phenotypes
Re
com
me
nd
atio
ns
Clinical
Report
Sample
acquisition
Lab test
Counselor/
Parents
EPIC
Counselor/
Parents
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Extending PGx Guidelines to Pediatrics CPIC guidelines are designed to help clinicians understand HOW available genetic test results should be used to optimize drug therapy not WHETHER tests should be ordered.
Developed primarily for adult patients from evidence-based review of studies in both adults and pediatric populations
Focus on FDA-approved indications and do not encompass all uses (off-label)
Assume full maturation of protein expression and function for the evaluated genes
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Applicability of PGx Guidelines to Pediatrics Pediatric pharmacogenetics requires a good understanding of:
clinical condition(s), demographic variability, approved use and off-label uses
the ontogeny (maturity projectory) of the genes and the impact of genetic variants on protein function/level
the interplay and the contribution of each of these confounding factors to the expected drug response variability
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Ontogeny analysis Review of studies documenting the development trajectory of protein encoded by tested genes
Limited availability of tissue samples (fetal and post-natal livers)
Some gene and protein function mature very early while others present a large variability during childhood (e.g CYP2C9)
Ontogenic CYP2C9 expression in the liver relative to adults. Dark blue columns represent population average. Light blue columns represent variability.
Hines RN. J Pharmacol Exp Ther. 2004 Mar;308(3):965-74.
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Maturation Trajectories Genes Maturation
TPMT, DPYD, VKORC1, CYP3A5 Fully mature at birth Remains constant
CYP2D6 Immature at birth
Increases rapidly to reach fully maturity within 4 weeks
CYP2C9, CYP2C19, SLCO1B1 Immature at birth
Increases progressively postnatally and during childhood to reach full maturity late childhood or at puberty – High variability
Limitation: level of expression of drug targets with or without variant are not well characterized during childhood, therefore the expression is assumed to be similar than the one in adults.
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Gene
Medication(s)
Evidence
Suitability
Notes
CYP2C19
Clopidogrel * yes but caution
Tricyclics/SSRIs * yes Indication dependent FDA Black-box in children
Voriconazole ** no - pediatric specific guidance
CYP2C9
Phenytoin ** yes but caution with specific pediatric dosing
Celecoxib ** yes with specific pediatric dosing
CYP2D6
Atomoxetine *** yes with specific pediatric dosing
Codeine *** yes but caution FDA Black-box in children
Ondansetron ** yes with specific pediatric dosing
Pimozide *** yes with specific pediatric dosing
Tricyclics/SSRIs * yes Indication dependent FDA Black-box in children
CYP3A5 Tacrolimus *** yes with specific pediatric dosing
DPYD Dihydropyrimidines *** yes
SLCO1B1 Simvastatin ** yes but caution
TPMT Thiopurines *** yes
CYP2C9/VKORC1 Warfarin *** no - pediatric specific guidance FDA Black-box in children
Adult PGx recommendations: suitability in Pediatrics
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Medication for a child with sickle cell disease
Hand-foot syndrome, pain episodes ◦ opioids and non-opioid analgesics
Surgery: splenectomy ◦ antiemetics, Opioids
Allogenic stem cell transplant ◦ immunosupressants
Venous thromboembolism ◦ anticoagulants
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Conditions Which drug High risk group Issue
Hand-foot syndrome, pain episodes
Codeine CYP2D6 poor metabolizer CYP2D6 Ultra-rapid metabolizer
Lack or efficacy Life-threatening respiratory depression
Morphine OPRM1 altered function Higher dose requirement
Surgery: splenectomy Fentanyl, morphine OPRM1 altered function Higher dose requirement
Ondansetron CYP2D6 ultra-rapid metabolizer Lack of efficacy
Allogenic stem cell transplant
Tacrolimus CYP3A5 normal and intermediate metabolizers
Higher dose requirement
Venous thromboembolism
Warfarin CYP2C9 poor/intermediate metabolizer and/or VKORC1 decreased expression phenotype
Lower dose requirement
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PGx benefits for a child with sickle cell disease
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Communicating Effectively Genetic test results are useless – understanding the implications is priceless
Alert on the consequences, not the genetic result
Tailor information to the audience – e.g. implications for the cardiologist, psychiatrist, or neurologist
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Clinician’s Curiosity is Limited by Time What we want to tell doctors
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What doctors want to know
Consider alternatives to Codeine #CYP2D6RapidMetabolizer
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Interpreting and Reporting Results
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Gene Maturation Trajectories
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What we have learned so far Inova’s MediMap program as an opportunity to screen a mostly healthy ethnically-diverse population and evaluate the uptake by families
Other PGx implementers within TSI network focuses on patients and mostly those that have comorbidities and likely to be polymedicated
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Inova’s Newborns with Actionable PGx
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3%
97% N= 8395
Non ActionablePhenotype
ActionablePhenotype
20.3
36.5
27.6
10.0
1.9
0.1
1
2
3
4
5
6
Nu
mb
er o
f ab
no
rmal
ph
eno
typ
es
Percentage of patients with one or more abnormal phenotype (s)
Genes Tested: CYP2D6, CYP2C9, CYP2C19, CYP3A5, SLCO1B1, VKORC1, TPMT
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Medicated Patients with Actionable and Informative PGx
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69.51%
19.59%
10.90% Actionable
Informative
No PGx guidance
N = 563,000 - 93% had an abnormal phenotype for at least one of the tested genes
Genes Tested: CYP2D6, CYP2C9, CYP2C19, CYP3A5, SLCO1B1, VKORC1
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Conclusions Rapid technological evolution is making genotype-guided prescribing attainable
PGx testing in children ◦ Despite limitation of extrapolating adult pharmacogenomics data to children, there are a number of
applications
◦ PGx information from adults is suitable with caution for Children in 75% of the cases and unclear in 25% of cases
◦ Current applications are highly informative when inadequate exposure is suspected
◦ A powerful tool that will allow us to consider pediatric patients as individual children
◦ Awareness and adoption of precision medicine is growing
◦ Focus on high value targets can accelerate adoption and diffusion
97% of Inova’s tested newborns are likely to benefit for PGx test
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Lifetime value of PGx testing
Neonates Infant Young Child Old Child - Adolescent Adult - Elderly
Surgery Coagulation Pain
Surgery Coagulation Pain
Surgery Coagulation Pain Psychiatry Transplantation Contraception
Surgery Coagulation Pain Psychiatry Transplantation Contraception Cardiovascular medicine Dementia
Medication Adverse Events Burden
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Acknowledgements From Translational Software
◦ Hannah Rule and Jared Munir
From Inova Translational Medicine Institute (ITMI) ◦ Dr John Deeken, COO
◦ Dr Ramaswany Iyer, Director of the Institute’s laboratory: Inova Genomics Laboratory and Biobank
◦ Dr Natalie Hauser, Medical geneticist
◦ Allison Mitchell and Julie Muskett, Certified genetic counselors
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Contact me at [email protected]