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Clinical Pharmacogenomics: Implications of New Developments for the NHS

Clinical Pharmacogenomics: Implications of New Developments for the NHS. Munir Pirmohamed NHS Chair of Pharmacogenetics Department of Molecular and Clinical Pharmacology Institute of Translational Medicine University of Liverpool. The Next 20 Years.

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Clinical Pharmacogenomics: Implications of New Developments for the NHS

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  1. Clinical Pharmacogenomics: Implications of New Developments for the NHS Munir Pirmohamed NHS Chair of Pharmacogenetics Department of Molecular and Clinical Pharmacology Institute of Translational Medicine University of Liverpool

  2. The Next 20 Years Prediction is very difficult, especially about the future Niels Bohr, Danish Physicist The best way to predict the future is to invent it Alan Kay, American Computer Scientist

  3. Pharmacogenetics (after Vogel, 1957) Pharmacogenomics (after Marshall, 1997) The study of the genetic basis for the difference between individuals in response to drugs Use of population genetic information for drug research, design and development Clinical management of drug therapy (drug dosing and drug choice) Definitions

  4. Evolution of Clinical Pharmacogenomics

  5. Metabolises azathioprine and 6-mercaptopurine Thioguanine accumulation inversely related to TPMT activity Associated with severe haemopoietic toxicity Molecular basis defined Phenotyping assays available and still used PATCHY UPTAKE and dependent of specialty Thiopurine Methyl Transferase (TPMT): A Phenotypic Test

  6. Evolution of Clinical Pharmacogenomics

  7. Association with HLA-B*5701 Clinical phenotype Clinical genotype Technology-Based Reduction in the Burden of ADRs: The Case of Abacavir Hypersensitivity

  8. Effect of Pharmacogenetics on Drug Usage

  9. Evolution of Clinical Pharmacogenomics

  10. Evolution of Clinical Pharmacogenomics

  11. Malignant Melanoma and BRAF Inhibitor: Baseline and 2 Weeks After

  12. Evidence What type of evidence is required for demonstration of clinical utility?

  13. Warfarin Pharmacogenetics:Controversy Regarding Genotyping Change in warfarin label (2007) and dosing tables (2010)

  14. Pharmacogenetic-Based Dosing: Warfarin Randomised Controlled Trial • FP7 sponsored EU trials • 3 trials: warfarin, phenprocoumon, acenocoumarol • 400-450 patients in each • %TIR as primary outcome measure • Point of Care test for genotyping European Union Pharmacogenetics of AntiCoagulant Therapy

  15. HLA Genotyping to Prevent Serious Adverse Drug Reactions • Since 2001, 22 new alleles associated with serious immune-mediated adverse drug reactions have been identified • Many of these have been based on genome wide association studies with initial results being replicated • Examples include: • Carbamazepine: HLA-B*1502 and Stevens-Johnson Syndrome • Carbamazepine: HL-A*3101 and hypersensitivity syndrome • Allopurinol: HLA-B*5801 and serious cutaneous adverse reactions • Flucloxacillin: HLA-B*5701 and cholestatic hepatitis • Are we going to require RCTs for all of these association? • Can we afford it?

  16. “Hierarchies of evidence should be replaced by accepting—indeed embracing—a diversity of approaches..... ...It is a plea to investigators to continue to develop and improve their methods; to decision makers to avoid adopting entrenched positions about the nature of evidence; and for both to accept that the interpretation of evidence requires judgment.”

  17. Evidence standards differ between non-genetic and genetic tests • 3 examples given: • Drug exposure • Prevention of adverse drug reactions • Health technology assessment

  18. Drug Exposure: Differential Evidential Standards • Example: Aztreonam SmPC • “after an initial usual dose, the dosage of aztreonam should be halved in patients with estimated creatinine clearances between 10 and 30 mL/min/1.73 m2” • Many different examples in hepatic and renal impairment with dose instructions based on PK studies and occasionally PK-PD modelling • No need for RCTs – in fact, would be impractical • However, a genetic polymorphism leading to same degree of change in drug exposure is often ignored and/or RCT data are required for implementation

  19. Differential Evidence Standards • Unfamiliarity with genetic tests • Lack of experience in interpretation • Perceived cost of genetic testing • Lack of availability of tests • Poor turnaround time recommendations on dosing evaluation in patients with polymorphisms in known metabolic pathways

  20. The Future? • 10 years • A whole genome costs less than £100 • Only needs to be done once • Good visualisation software • Patient who requires a drug metabolised by CYP2D6 • Absent in 8% of the population • Are you going to ignore the genetic data in the patient’s medical record?

  21. Patient Empowerment

  22. Translation into Clinical Practice Lost in Translation • Major on-ongoing advances • Identify evidence needs • Consistency in evidence standards • Streamlined processes for adoption into NHS • Innovation into practice a major driver for the AHSN Poste, Nature, 2011

  23. Acknowledgements • Collaborators • Wellcome Trust Sanger Institute (Panos Deloukas, Stephane Bourgeois, Trevor Lawley, Gordon Dougan) • University of Bangor (Dyfrig Hughes) • Epigen, DILIGEN, iSAEC • Funders • Department of Health (NHS Chair of Pharmacogenetics), NIHR programme, MRC, EU-FP7, Wellcome Trust • Dept of Pharmacology • Ana Alfirevic, Dean Naisbitt, Andrea Jorgensen, Dan Carr, Mas Chaponda, Fabio Miyajima, Kevin Park plus many others

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