Tailoring Medication to Patient Characteristics

1. Tailoring Medication to Patient Characteristics Farrokh Alemi, Ph.D.Georgetown University

2. Patent • This presentation is based on a patent application on personalized medication held by George Mason University • Scientists and government organizations have free access to this patent

3. Proposal • Improve quality of care of rural veterans • Provide personalized advice on antidepressants

4. Case of George • Military service • Industrial manager, polite, defines himself a “medieval knight.” • First depression episode at 26, treated with clomipramine, dose unknown. • At 30 married with a daughter • At 45 return of depressive symptoms, treated with fluvoxamine 200–300 mg and mirtazapine 15 mg • Depression continues, loss of interest in work, difficulty with bi-polar daughter • Loss of daughter, divorce and loss of work • At 48, suicide

5. First Treatment not Enough • Who responds to SSRI citalopram? • Highly educated • Currently employed • Caucasian women • Few complicating psychiatric or medical disorders. At least 70% of patients did not respond. Beyond Efficacy: The STAR*D Trial. By Thomas R. Insel Am J Psychiatry. available in PMC 2006 September 30.

6. Medication Benchmarks: Selection of Antidepressants • 70% not responsive • Six weeks before efficacy can be examined • Sometimes 2-3 years searching for right medication

7. What We Want? Tell me what works for me.

8. EHR Patient data stored Patient data retrieved Care reminders Patient info displayed Care Decisions Data of others Data warehousing Clinical Education Discovery Rethinking Role of Data

9. Rethinking Role of Data EHR Patient data stored Patient data retrieved Care reminders Patient info displayed Care Decisions Data of others Similar patients Data warehousing Clinical Education Discovery

10. Rethinking Role of Data EHR Patient data stored Patient data retrieved Analytics: care forecasts Patient info displayed Care Decisions Data of others Similar patients Data warehousing Clinical Education Discovery

11. Age Gender Race Ethnicity Concurrent drugs Methadone Buprenorphine Diet Grapefruit Genetics CYP2D6 CYP2C19 CYP3A4 CYP1A2 Concurrent illness Cancer Diabetes Medication Benchmarks: Selection of Antidepressants

12. Medication Benchmarks: Selection of Antidepressants • Steps in Algorithm • Select characteristics that make patient different from norm • Calculate similarity to patients in the database Based on GMU patent. Confidential communication

13. Medication Benchmarks: Selection of Antidepressants • Steps in Algorithm • Select characteristics that make patient different from norm • Calculate similarity to patients in the database Number of features matched Number of features matched Features in one but not the other Based on GMU patent. Confidential communication

14. Medication Benchmarks: Selection of Antidepressants • Steps in Algorithm • Reported average outcomes for different anti-depressants weighted by similarity of patients: Based on GMU patent. Confidential communication

15. Medication Benchmarks: Selection of Antidepressants • Easy to implement • 8 lines of SQL code • Can work within any EHR • Concurrent analysis • No need to export data. No need for consent • No need to use data warehouses • No need to require same data on all patients

16. Medication Benchmarks: Selection of Antidepressants • Easy to implement • 8 lines of SQL code • Can work within any EHR • Concurrent analysis • No need to export data. No need for consent • Current or warehoused data • No need to require same data on all patients

17. Medication Benchmarks: Selection of Antidepressants • Easy to implement • 8 lines of SQL code • Can work within any EHR • Concurrent analysis • No need to export data. No need for consent • Current or warehoused data • No need to require same data on all patients

18. Data Source • Sequenced Treatment Alternatives to Relieve Depression (STAR*D) • 4,041 outpatients with non-psychotic depression • 23 psychiatric and 18 primary care sites • 12-week course of the SSRI citalopram • Adjunct or replacement treatment in three subsequent phases

19. Technological Fix • Technology is available • Data is available • Analytical procedure is simple Will there be fewer George’s among us?