Brad Esarey VP Business Operations

A need for Personalized Medicine

PGx Integration: Role of the Clinical Laboratory Catalyze the delivery of biotechnology products to healthcare consumers Overcome barriers to genotyping Develop genetic profiling strategies to maximize sensitivity and specificity of predicting phenotype Provide availability of testing Develop methods to reduce technical difficulty, cost Improve interpretations

Pharmacogenetics Links differences in gene structure (inherited polymorphism) to drug metabolism and response Genetic polymorphism Drug metabolism & response (Genotype) (Phenotype) Why is this important ?

~60% of meds in top 20 list causing ADRs are linked to a genetic variation 122 drugs have FDA box warnings related to genetics

Key: This Connection Explanatory Use Predictive Use Decision for Drug Treatment CYP Genotyping Therapy Refractoriness or Adverse Events Dose Adjustment According to Efficacy and Adverse Events Standard Drug and Dose Predictive Use Decision for Drug Treatment CYP Genotyping Further Adjustment According to Efficacy and Adverse Events Drug Selection and Dosage Based on Genotype Key: This Connection

PGXL Enables Transformation Intuitive Medicine Precision Medicine Indicators Suggest: Diagnostic services will trump therapeutics (Clayton M Christenson in: The Innovator’s Prescription, MacGraw Hill, 2009)

Applications of pharmacogenomics Individualizing drug therapy selection Predicting adverse reactions, dosing, response Identify increased sensitivity to drug interactions

Clinical Applications of Pharmacogenetic Information Anti-coagulation Warfarin Plavix (clopidogrel) Psychiatry Anti-depressants Oncology KRAS Tamoxifen EGFR’s Pain management Codeine Hydrocodone Oxycodone

Medications and metabolic pathways CYP2C9   CELECOXIB CELEBREX IBUPROFEN ADVIL, MOTRIN NAPROXEN ALEVE GLYBURIDE DIABETA GLIPIZIDE GLUCOTROL TOLBUTAMIDE ORINASE GLIMEPIRIDE AMARYL PHENYTOIN DILANTIN FLUVASTATIN LESCOL LOSARTAN COZAAR CYP2C9/VKORC1 WARFARIN COUMADIN CYP2C19 CLOPIDOGREL PLAVIX CITALOPRAM CELEXA ESCITALOPRAM VARIOUS BRANDS IMIPRAMINE TOFRANIL SERTRALINE ZOLOFT OMEPRAZOLE PRILOSEC ESOMEPRAZOLE NEXIUM PANTOPRAZOLE PROTONIX RABEPRAZOLE ACIPHEX LANSOPRAZOLE PREVACID DIAZEPAM VALIUM NELFINAVIR VIRACEPT  

Medications and CYP2D6 metabolic pathway ANTIDEPRESSANTS AMITRIPTYLINE VARIOUS BRAND NAMES CLOMIPRAMINE ANAFRANIL DESIPRAMINE NORPRAMIN DOXEPIN SINEQUAN IMIPRAMINE TOFRANIL NORTRYPTYLINE PAMELOR, AVENTYL   ANTI-PSYCHOTICS SSRI’S ARIPIPRAZOLE ABILIFY FLUOXETINE PROZAC MAPROTOLINE LUDIOMIL PAROXETINE PAXIL RISPERIDONE RISPERIDOL BETA-BLOCKERS CARVEDILOL COREG METOPROLOL TOPROL-XL PROPANOLOL VARIOUS BRAND NAMES OPIOIDS CODEINE CODEINE PHOSPHATE OXYCODONE OXYCONTIN HYDROCODONE VARIOUS BRAND NAMES DESTROMETHORPHAN VARIOUS BRAND NAMES TRAMADOL ULTRAM, VARIOUS BRAND NAMES   SNRI’S ATOMOXETINE STRATTERA VENLAFAXINE EFFEXOR OTHERS DONEPEZIL ARICEPT FLECANIDE TAMBOCOR FLUVASTATIN LESCOL LORATIDINE CLARITIN PROPAFENONE RYTHMOL TAMOXIFEN VARIOUS BRAND NAMES

Vision: enable transition of pharmacogenetic diagnostics into actionable healthcare results Mission and Core Business Strategies: Provide Clinical Diagnostic Services (healthcare providers for direct patient care) Support Development of Diagnostics (discovery & translation of biological markers)

Product Lines PGXL is uniquely positioned Cardiovascular: - Anticoagulation - HTN/CHF Pain Management: - Opiods Behavioral Health: - ADHD - Schizophrenia - Depression Oncology: - Cancer therapy - Prevention Respiratory: - Asthma - COPD PGXL is uniquely positioned

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Current Test Menu MOLECULAR ONCOLOGY PHARMCOGENETICS - CYP1A2 - CYP2C9 - CYP2C9/VKORC1 - CYP2C19 - CYP2D6 - NAT2 - HLA-B*1502 Carbamazepine sensitivity - HLA-B*5701 Abacavir sensitivity - 5-HTTLPR Serotonin Transporter - MTHFR - Factor II (Prothrombin 20210 G>A) - Factor V Leiden - Hepatitis-B Virus DNA Quantitative - CYP2D6 tamoxifen KRAS - BRAF BCR/ABL (quantitative) - BCR/ABL Kinase Domain mutations - JAK2 (quantitative) - BCL1 - BCL2 - PML-RARα - c-KIT - EGFR - EGFR (FISH) - HER2/neu (FISH) - ALK (FISH) - DPD/TYMS - TPMT MOLECULAR ONCOLOGY PHARMCOGENETICS - MPA,serum - MPA + MPA-G, serum THERAPEUTIC DRUG MONITORING 15

PGx of Warfarin Overview Quick review of the problem Review of Pharmacokinetic Basics Application of knowledge

FDA Updates Coumadin Label Genetic Information may improve initial dosing estimate for individual patients The U.S. Food and Drug Administration announced today the approval of updated labeling for the widely used blood-thinning drug, Coumadin, to explain that people's genetic makeup may influence how they respond to the drug. The labeling change highlights the opportunity for healthcare providers to use genetic tests to improve their initial estimate of what is a reasonable warfarin dose for individual patients. Testing may help optimize the use of warfarin and lower the risk of bleeding complications from the drug. U.S. Food and Drug Administration August 16, 2007

Reynolds K et al. Pers Med 2007;4(1):11-31.

Pharmacogenetics of Warfarin Inactivated and eliminated via Cytochrome P4502C9 metabolism 40% of populations have deficient CYP2C9 Inhibits Vitamin K epoxide reductase complex > 70% of population have decreased VKOR and are more sensitive to warfarin

Dose effectiveness should be assessed at steady-state CYP2C9 *2 and *3 delay time to reach steady-state Increase blood concentration Dose effectiveness should be assessed at steady-state Linder et al. J Thrombosis & Thrombolysis 2002;14:227-232 Confidential

Variables influencing maintenance dose. Optimal WARFARIN dose can be calculated based on AGE, GENDER, WEIGHT and PHARMACOGENETICS Zhu Y et al. Clin Chem 2007;53(7):1199-1205.

Impact of Testing Estimate Maintenance Dose Requirement Guides dose selection Estimate of Time to Reach Steady-state Avoid Mis-interpretation of INR’s Avoid Premature Dosage Changes

© Copyright 2007 Pharmacogenetics Diagnostic Laboratory, LLC © Copyright 2007 Pharmacogenetics Diagnostic Laboratory, LLC. All rights reserved. Duplication of material prohibited.

Application of Pharmacogenomics to Anti-platelet therapy

Antiplatelet Response Clopidogrel (Plavix) is a pro-drug which is converted to an active metabolite by hepatic cytochrome P4502C19 (CYP2C19). ~ 30% of patients have deficiency in CYP2C19

Influence of CYP2C19 on Clopidogrel Response

Applications of PGx in Pain Management

Pharmacokinetics: genetic variation in cytochrome P450’s Decreased drug clearance Mis-interpretation of over compliance Ultra-rapid drug clearance Mis-interpretation of drug diversion Mis-interpretation of poor compliance

Cytochrome P4502D6 Substrates Pain management Hydrocodone Oxycodone Methadone Propoxyphene Codeine Others …. In addition many drugs commonly co-prescribed with pain management medications Antidepressants Anti-anxiety

Genetic polymorphism of CYP2D6 Ultra-rapid metabolizers (UM) 3 – 7 % of population Extensive metabolizers (EM) 55 – 60 % of population Intermediate metabolizers (IM) 25 – 30% of population Poor Metabolizers (PM) 5 – 10 % of population

Example: Codeine Principal metabolism by CYP2D6 Pro-drug to morphine CYP2D6 PM: in adequate morphine CYP2D6 UM: morphine poisoning

Case Report: Neonatal Morphine Overdose Full-term healthy male infant showed intermittent periods of difficulty in breastfeeding and lethargy starting on day 7 Day 11 pediatric visit baby regained birth weight Day 12 gray skin and milk intake had fallen Baby found dead on day 13 Postmortem analysis showed no anatomical anomalies Koren et al. Lancet 2006;368:704.

Toxicology Results Blood concentration of morphine = 70 ng/mL neonates breastfed by mothers receiving codeine typically have morphine serum concentrations of 0–2.2 ng/mL Day 10 breast milk morphine concentration = 87 ng/mL Typical range after repeated maternal codeine doses of 60 mg every 6 h is 1.9–20.5 ng/mL The mother was prescribed 2 weeks codeine 30 mg + acetaminophen 500 mg (Tylenol #3) after birth for episiotomy pain 4 tabs first day, but only 2 tabs daily thereafter because of maternal somnolence and constipation Koren et al. Lancet 2006;368:704.

CYP2D6 Genotype Analysis CYP2D6 *1/*2xN = Ultra-rapid Metabolizer (gene duplication) (UM) Leads to increased formation of morphine from codeine Maternal grandfather, the father, and the infant had 2 functional CYP2D6 alleles (Extensive Metabolizer, EM) The maternal grandmother was a UM Koren et al. Lancet 2006;368:704.

Clinical Case Conclusions The clinical and laboratory picture was consistent with neonatal death from opioid toxicity Most of the analgesic and CNS depressant effects of codeine are secondary to its metabolism to morphine by CYP2D6 Neonates invariably have impaired capacity to metabolize and eliminate morphine Koren et al. Lancet 2006;368:704.

Case Conclusions, cont’d Codeine is a commonly used analgesic after labor Episiotomy Caesarean section American Academy of Pediatrics lists codeine as compatible with breastfeeding, despite lack of sufficient published data to support this recommendation Inherited differences in CYP2D6 can be life-threatening for some breastfed babies “Codeine cannot be considered as a safe drug for all infants during breastfeeding” CYP2D6 UM frequency 1.5 - 2% in Caucasians and Asians 14% in African Americans 29% in Ethiopians Koren et al. Lancet 2006;368:704.

Strategies to manage breastfeeding while on codeine Action Advantages Disadvantages Avoid codeine; use alternative Avoids potential neonatal toxicity Potential uncontrolled pain Avoid high-dose codeine (240mg/d) for more than a few days Minimizes potential neonatal toxicity Uncontrolled pain; dose still too high for UMs Avoid breastfeeding while on codeine Loss of breastfeeding benefits Inform and monitor for signs of opioid toxicity Early Intervention and prevention of serious toxicity Parental anxiety and false-positive toxicity Genotype mothers for CYP2D6 Predicts risk of excess morphine production Expensive, not presently routine Adapted from Koren et al. Lancet 2006;368:704.

Routine CYP2D6 testing IS available Metabolizer status (phenotype) CYP2D6 Genotyping Routine CYP2D6 testing IS available Metabolizer status (phenotype) can be predicted Predicts risk of toxicity, therapeutic failure, and promotes optimal outcomes for patients

Other CYP2D6 Genotyping Considerations CYP2D6 metabolizes 20-25% of all current medications CYP2D6 inactivates medications antidepressants, antipsychotics, beta- blockers, antiarrhythmics CYP2D6 activates medications opioids, tamoxifen CYP2D6 is inhibited by medications antidepressants (SSRIs in particular), antipsychotics, certain antimicrobials, quinidine, amiodarone CYP2D6 is induced by medications rifampin, carbamazepine, phenobarbital, ritonavir

Consultation Services PGXL provides state-of-the-art interpretive reports with actionable guidance PGXL medical directors are available for clinical consultation with ordering practitioners before and after testing Ongoing VIP review consultation after 50-100 patients tested Educational lecture series and/or CME events as needed

Diagnostic Testing Clinical testing is available Must be performed by high-complexity CLIA-certified laboratory 5-7 business day TAT Whole blood or cheek swab samples Genotype result with phenotype interpretation

Patient Information: Genetic Drug Sensitivity Testing Why test my genes before prescribing a drug? Just as gene variation controls hair or eye color, it also controls how the body reacts to certain drugs. Before prescribing one of those drugs, your physician may give you a genotype test to make sure the drug will be safe and effective for you. A genotype is an analysis of some aspect of your genetic make-up. Knowing your genotype will help you and your doctor choose the most effective treatment path. What is CYP450? CytochromeP450, abbreviated CYP450, is a complex of genes that controls liver enzymes that digest certain drugs. Those drugs include Plavix®, Coumadin®, warfarin, beta blockers, common pain medications and antidepressants, among many others. Different genes within the CYP450 complex control the metabolization of different drugs. CYP2C19, for example, indicates Plavix sensitivity, and CYP2C9 is commonly analyzed before prescribing Coumadin/warfarin. What will the test tell me? Specifically, how quickly your body filters a given drug out of your bloodstream. A high metabolizer flushes drugs out of the body quickly, and might never realize any benefit from taking a “normal” dose. A poor metabolizer is just the opposite, with a “normal” dose building to potentially dangerous levels. Understanding how quickly you will metabolize a drug helps your doctor calculate the safest, most effective dose for you. What is required to perform this test? You will need to provide a DNA sample using a buccal swab. A buccal swab is a sterile cotton swab made for DNA collection. You gather DNA simply and painlessly by rubbing the buccal swabs on the insides of your cheeks. The swabs are then sealed and shipped to the lab for testing. What happens to my DNA once the test is complete? Your privacy is assured. Samples and genetic information are stored securely in accord with HIPAA and other government regulations. Is there a cost for this test? This is a routine clinical laboratory test covered by Medicare and most private insurance plans. There may be a co-pay, depending on the specifics of your policy. How do I get my test results? Results will be sent to your doctor 3-5 business days after your sample is collected. All tests are performed by PGXL Laboratories, Louisville, KY – 877-564-2199 – CLIA License 18D0983143.

The Actual In-service

DON’T

DO’S Four swabs per test Blood is ok One swab at a time Two swabs per cheek Thirty seconds per swab One minute dry Blood is ok Swabs in envelope Envelopes in Ziploc Forms in Pouch

QUESTIONS?

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