Then you will respond to the main postings of at least two of the other learners who have answered questions different from yours.

STUDENT’S POST 1

Pharmacogenomics (PGx) Testing Benefits

Pharmacogenomics is the study of how an individual’s genetic inheritance affects the body’s response to drugs (Aneesh et al., 2009). A goal of pharmacogenomic is to create a way to select a safer drug with less side effects the first time. Environment, diet, age, lifestyle, and state of health all can influence a person’s response to medicines, but understanding an individual’s genetic makeup is thought to be the key to creating personalized drugs with greater efficacy and safety (Aneesh et al., 2009). In addition to factors like age, gender, and diet that can affect individual responses to any course of treatment, the success of psychiatric drugs is often limited by patients’ genetic variation (Kastrinos et al., 2021).

Identifying a successful drug regimen often requires psychiatric patients to undergo an extensive trial and error process, enduring numerous healthcare visits, missed work days, diminished productivity, disability claims, and exorbitant treatment costs (Kastrinos et al., 2021). Pre-emptive pharmacogenomic (PGx) testing can potentially reduce adverse drug reactions and its associated costs (Chan et al., 2018).   PGx testing will look at the metabolizing of a drug and how a patient will respond to a particular drug. Ideally this additional information minimizes the risks of toxicity and increases drug safety for both individual patients and society as a whole (Kastrinos et al., 2021). This would allow for the prescriber to select the right drug, the right dose, and limit side effects. The main aims of it are personalized therapy, improvement in efficacy and reduction in adverse drug reactions, correlations of genotype with clinical genotype, identification of novel targets for new drugs, and pharmacogenetic profiling of patients to predict disease susceptibility and drug response (Aneesh et al., 2009). Lee et al., found that participants experiencing pharmcogenomic-guided care were more receptive toward pharmacogenomic information being used than traditional care participants (2017).

Depression and anxiety are two mental illnesses that are showing promising results from treatment attributed to PGx testing. Elderly depression is concerning because of comorbidities and the right drug needs to be selected first. Decades of investigation into the etiology of geriatric depression have implicated a likely reciprocal relationship among several age-related comorbidities, including cerebrovascular disease, neuroinflammation, and cognitive decline  and dementia (Forester et al., 2021). There are multiple issues that can allow geriatric depression to be hidden such as sleep disorders, obesity and can be affected by psychosocial factors.  There are multiple issues when prescribing medications to geriatric patients such as increased risk for drug interactions, renal and liver impairments, polypharmacy, and compliance. PGx could potentially offer a unique benefit to psychiatric patients, providing information about patients’ reaction to medications that could reduce the time and financial burdens of drug optimization (Kastrinos et al., 2021). Current investigations of PGx results contribute to a growing body of work evaluating the impact of pharmacogenomic testing to inform antidepressant medication treatment of depression and anxiety (Papastergiou et al., 2021). Combinational pharmacogenomic test-informed medication selection improved outcomes over TAU (treatment as usual) among older adults with depression (Forester, 2021).

 

References

Aneesh, T. P., Sekhar, S. M., Jose, A., Chandran, L., & Zachariah, S. M. (2009). Pharmacogenomics: The right drug to the right person. Journal of Clinical Medicine Research1(4), 191–194. https://doi.org/10.4021/jocmr2009.08.1255 (Links to an external site.)

Chan, S., Ng, H., Sung, C., Chan, A., Winther, M. D., Brunham, L. R., & Wee, H.-L. (2018). Economic burden of adverse drug reactions and potential for pharmacogenomic testing in singaporean adults. The Pharmacogenomics Journal19(4), 401–410. https://doi.org/10.1038/s41397-018-0053-1 (Links to an external site.)

Forester, B. P., Parikh, S. V., Weisenbach, S., Ajilore, O., Vahia, I., Rothschild, A. J., Thase, M. E., Dunlop, B. W., DeBattista, C., Conway, C. R., Shelton, R. C., Macaluso, M., Li, J., Traxler, P., Logan, J., Brown, L., Dechairo, B., & Greden, J. F. (2021). Combinatorial pharmacogenomic testing improves outcomes for older adults with depression. FOCUS19(1), 76–85. https://doi.org/10.1176/appi.focus.19107 (Links to an external site.)

Kastrinos, A., Campbell-Salome, G., Shelton, S., Peterson, E. B., & Bylund, C. L. (2021). Pgx in psychiatry: Patients’ knowledge, interest, and uncertainty management preferences in the context of pharmacogenomic testing. Patient Education and Counseling104(4), 732–738. https://doi.org/10.1016/j.pec.2020.12.021 (Links to an external site.)

Lee, Y., McKillip, R. P., Borden, B. A., Klammer, C. E., Ratain, M. J., & O’Donnell, P. H. (2017). Assessment of patient perceptions of genomic testing to inform pharmacogenomic implementation. Pharmacogenetics and Genomics27(5), 179–189. https://doi.org/10.1097/fpc.0000000000000275 (Links to an external site.)

Papastergiou, J., Quilty, L. C., Li, W., Thiruchselvam, T., Jain, E., Gove, P., Mandlsohn, L., den Bemt, B., & Pojskic, N. (2021). Pharmacogenomics guided versus standard antidepressant treatment in a community pharmacy setting: A randomized controlled trial. Clinical and Translational Science14(4), 1359–1368. https://doi.org/10.1111/cts.12986

STUDENT’S POST 2:

Pharmacogenomic testing:

Pharmacogenomic testing (PGx) is certainly an exciting topic in healthcare when caring for those struggling with mental health disorders. Patients struggle with side effects, metabolism, and non-effective treatment regimens that often lead to discouragement in mental healthcare. Psychotropic medications are certainly not sugar pills and have the potential for significant side effects such as adverse drug reactions (ADRs). Consider if a provider could know the risk that a patient had for an adverse drug reaction before the medication was prescribed, taken, and metabolized. PGx testing does exactly that and focuses on how an individual patient’s genetic makeup will response to a prescribed medication (Turongkaravee et al., 2021).   In essence, this testing guides how does a specific person metabolizes the medication (Virelli et al., 2021).

Genetics are certainly an important part of the neurobiological aspect of mental health and PGx is part of an exciting and developing part of psychiatry care (Sadock et al., 2017).  Drug/drug interactions can be significant with psychotropics and other medications. There can be risky outcomes for patients, especially when considering the gene specifically CYP450 that is relevant in about 50% of current medications (Sadock et al., 2017). This type of treatment allows for a personal approach to mental health care instead of the idea of trial and error to help patients and clinicians have an appropriate treatment regimen and a better understanding and education of the potential risks and side effects (Sadock et al., 2017).   

Benefits of testing:

Genomind (2022) does a great job of explaining the purpose of this diagnostic testing that really is the beginning point of mental health care and a resource for prescribers to help guide us with evidence for clinical decision making. It is amazing to read statistics on the website. Genomind (2022) has statistically noted improvement in around 87% of patients that have been tested. This is a huge number to consider the ramifications of improved mental health. What a good option for treatment.

This is such a valuable resource for patients and helps with safety and decreased anxiety when caring for patients struggling with mental health disorders. Mental health care can sometimes get really messy with working diagnosis/changing diagnosis, signs/symptoms that significantly affect outcomes of the patient lived experience, and often changing medication regimens. We cannot completely explain the “why” of certain diagnosis but often discuss common thoughts or ideas from the literature. Think about how exhausting this is for patients that are already struggling with cognitive function and finding hope when they feel poorly. Pharmacogenomic testing could also be called “peace of mind”. Patients can be comfortable having educated discussions with providers and understanding how their body metabolizes and excretes with the best medication choices for optimal outcomes. How invaluable this is to patients.

Changing medications regularly can increase the risk of drug/drug interactions, as well as frustration and time. Patients want to get help and get back to their lives. Psychotropic medications are certainly serious, they do have significant side effects, so working to minimize the side effects. These all should be reasons to get this type of genetic testing. Thankfully, these companies do work with insurance companies and Medicare/Medicaid. This does allow patients the opportunity to have access to this cost-effective option.

Evidence for clinician use in practice:

It is important to consider what the barriers are for pharmacogenomic testing so that we can better understand how to apply and incorporate this testing into clinical practice. Current clinical barriers to consider include patient/clinician awareness, cost, and clinical evidence (Virelli et al., 2021).  What is currently limiting recommendations of testing is a significant lack of randomized control trials (RCTs) that have been published which are very costly. There are several clinical trials that have shown positive outcomes in the use of pharmacogenomic testing in the clinical setting (Virelli et al., 2021).

Cost has been another consideration to think about in barriers for use. Many studies have identified PGx testing as cost-effective treatment (Virelli et al., 2021). It is important to consider that this is not simply related to the cost of a test versus not getting tested. Consider the cost that could be saved if having the potential to find a treatment that was beneficial to the individual patient. This would not just be a cost saving from money. Patients would benefit from improved outcomes and positive outcomes can improve patients and their families’ lives.

Lack of knowledge of how and why to increase PGx testing is another barrier (Virelli et al., 2021). If providers aren’t aware or clear of the knowledge and benefits for this tool then this would definitely affect a patient’s ability to get this testing orders. In one study only about half of the providers were informed about genetic testing (Virelli et al., 2021). Providers must become educated on the benefits of this testing for buy-in for positive change, otherwise no one will be ordering PGx testing.

Current recommendations for consideration include that testing should not be used to prescribe an initial psychotropic medication and should be used with caution (Kumar & Kearney, 2021). This is another tool that can be used in healthcare but should never replace the clinician and good clinical judgment. Completing a good psychiatric comprehensive exam is certainly the start of a good clinician visit. Using sound clinical judgement plus the use of potential tools can help improve the patient outcome. Patients are what guide each and every thing that is done in clinical practice and should guide the choice to use pharmacogenomic testing appropriately in clinical practice.

References

Genomind. (2022). Upgrade your practice with Genomind. https://www.genomind.com/clinicians?hsCtaTracking=c1eeed39-64b3-4855-813b-907b6b90917a%7Cc46793eb-12bc-4906-96fe-5d73a4f42651 (Links to an external site.)

Kumar, A., & Kearney, A. (2021). The use of pharmacogenetic testing in psychiatry. Journal of the American Association of Nurse Practitioners, 31(11), 849-851. https://oce-ovid-com.northernkentuckyuniversity.idm.oclc.org/article/01741002-202111000-00002/HTML (Links to an external site.)

Sadock, B., Sadock, V.A., & Ruiz, P. (2017). Kaplan & Sadock’s concise textbook of clinical psychiatry (4th ed.) Lippincott Williams & Wilkins.    

Turongkaravee, S., Jittikoon, J., Rochanathimoke, O., Boyd, K., Wu, O., & Chaikledkaew, U. (2021). 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 Services Research, 21(1042), 1-23. https://doi.org/10.1186/s12913-021-07025-8 (Links to an external site.)

Virelli, C. R., Mohiuddin, A. G., & Kennedy, J. L. (2021). Barriers to clinical adoption of pharmacogenomic testing in psychiatry: A critical analysis. Translational Psychiatry, 11(1), 1-9.  http://dx.doi.org/10.1038/s41398-021-01600-7