Preemptive genotyping for personalized medicine: design of the right drug, right dose, right time-using genomic data to individualize treatment protocol.

Bielinski SJ1, Olson JE2, Pathak J2, Weinshilboum RM3, Wang L4, Lyke KJ2, Ryu E2, Targonski PV5, Van Norstrand MD6, Hathcock MA2, Takahashi PY5,McCormick JB7, Johnson KJ8, Maschke KJ9, Rohrer Vitek CR8, Ellingson MS8, Wieben ED10, Farrugia G11, Morrisette JA2, Kruckeberg KJ12, Bruflat JK12,Peterson LM12, Blommel JH12, Skierka JM12, Ferber MJ12, Black JL12, Baudhuin LM12, Klee EW2, Ross JL13, Veldhuizen TL8, Schultz CG8, Caraballo PJ14,Freimuth RR2, Chute CG2, Kullo IJ15.

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Abstract

OBJECTIVE:

To report the design and implementation of the Right Drug, Right Dose, Right Time-Using Genomic Data to Individualize Treatment protocol that was developed to test the concept that prescribers can deliver genome-guided therapy at the point of care by using preemptive pharmacogenomics (PGx) data and clinical decision support (CDS) integrated into the electronic medical record (EMR).

PATIENTS AND METHODS:

We used a multivariate prediction model to identify patients with a high risk of initiating statin therapy within 3 years. The model was used to target a study cohort most likely to benefit from preemptive PGx testing among the Mayo Clinic Biobank participants, with a recruitment goal of 1000 patients. We used a Cox proportional hazards model with variables selected through the Lasso shrinkage method. An operational CDS model was adapted to implement PGx rules within the EMR.

RESULTS:

The prediction model included age, sex, race, and 6 chronic diseases categorized by the Clinical Classifications Software for International Classification of Diseases, Ninth Revision codes (dyslipidemia, diabetes, peripheral atherosclerosis, disease of the blood-forming organs, coronary atherosclerosis and other heart diseases, and hypertension). Of the 2000 Biobank participants invited, 1013 (51%) provided blood samples, 256 (13%) declined participation, 555 (28%) did not respond, and 176 (9%) consented but did not provide a blood sample within the recruitment window (October 4, 2012, through March 20, 2013). Preemptive PGx testing included CYP2D6 genotyping and targeted sequencing of 84 PGx genes. Synchronous real-time CDS was integrated into the EMR and flagged potential patient-specific drug-gene interactions and provided therapeutic guidance.

CONCLUSION:

This translational project provides an opportunity to begin to evaluate the impact of preemptive sequencing and EMR-driven genome-guided therapy. These interventions will improve understanding and implementation of genomic data in clinical practice.

KEYWORDS:

CAB, CAP, CDS, CGSL, CLIA, Clinical Genome Sequencing Laboratory, Clinical Laboratory Improvement Amendments, College of American Pathologists, Community Advisory Board, EMR, Electronic Medical Record and Genomics, FDA, Food and Drug Administration, NGS, PGL, PGRN, PGx, Personalized Genomics Laboratory, Pharmacogenomics Research Network, RIGHT, The Right Drug, Right Dose, Right Time—Using Genomic Data to Individualize Treatment, clinical decision support, eMERGE, electronic medical record, next-generation sequencing, pharmacogenomics