In January 2015, President Obama’s Precision Medicine Initiative mandated the promotion of “more accurate diagnosis and personalized management of health and disease.” However, according to the authors, healthcare professionals face several challenges in implementing this directive:
- Discomfort ordering and/or interpreting genetic tests
- Lack of training in pharmacogenomics
- Continuous and rapid emergence of data
- Varied insurance coverage and reimbursement
The authors note that to date, “routine preemptive pharmacogenomics testing for antidepressant selection is not recommended, for reasons that include lack of large-scale clinical trials supporting its use, cost-effectiveness, and insurance coverage.” Such testing may not be covered due to lack of strong evidence of clinical utility; agents that are covered are those with pharmacogenomics information in the drug label.
However, “clinical genotyping for CYP2D6- and CYP2C19-metabolized medications is increasingly considered in clinical practice for treatment-resistant depression, when higher dosing for obsessive-compulsive disorder (OCD) is anticipated, if there is a known family history of CYP2D6/CYP2C19 poor metabolizer phenotype, and in patients taking multiple drugs concurrently,” he noted.
Until the cost of genetic testing declines, insurance companies cover such tests, and more robust clinical data are published, using currently available evidence and following guidelines such as those recommended by the CPIC remain the goal for “more precise medical practice in psychiatry,” they concluded.
1. Nassan M, Nicholson WT, Elliott MA, Rohrer CR, Black JL, Frye MA. Pharmacokinetic pharmacogenetic prescribing guidelines for antidepressants: A template for psychiatric precision medicine. Mayo Clin Proc. 2016;91(7):897-907.
2. Relling MV, Klein TE. CPIC: Clinical pharmacogenetics implementation. Consortium of the Pharmacogenomics Research Network. Nature. 2011;89(3):464-467.