Foot and Ankle Specialist practicing for over 30 years in the Hudson Valley. Operates six successful practices in the New York Market. His passion has always been health, wellness and changing lives through leadership and inspiring individuals to challenge their limits. Dr. Tumen has completed 9 Marathons including the NYC Marathon 7 times and enjoys endurance trail runs. Dr. Doug Tumen Operates 6 practices in the Hudson Valley NY Scientific Advisory Board Member

Fastest turn-around time business days Developed the solution for processing PGX Developed over 500 tests, incl early cancer screening that detects some types of cancer up to 6 months earlier than any other test Far superior toxicology results (tests for 56 drugs) Move urine specimens with blood immediately to early cancer screen, so can be detected earlier Revenue sharing program for qualified facilities Easy to read reports Advisors available for consultation daily FREE SUPPLIES & SHIPPING WALLET CARD for quick reference for any dr

Pharmacogenetics is the study of genetic variations that influence individual response to drugs. “It is the science that allows us to predict a response to drugs, on an individual’s complete genetic makeup.” − Felix Frueh, Associate Director of Genomics, FDA Helps prescribers individualize drug therapy, decrease the chance for adverse drug events, and increase the effectiveness of drugs.

Pharmacogenomics = Tailored drug therapy based on genetically determined variation to increase effectiveness and decrease side effects. To the physician this will mean: Better, safer drugs the first time - Recovery time will go down and safety will go up as the likelihood of adverse reactions goes down, or is eliminated altogether. More accurate methods of determining appropriate drug dosages Current methods of basing dosages on weight and age will be replaced with dosages based on a person's genetics as an additional and critical biomarker --how well the body processes the medicine and the time it takes to metabolize it.” From the website of the American Medical Association medicine/current-topics/pharmacogenomics.page?

Availability of testing in your medical practice with ease Non-invasive buccal swab. Covered by most insurance companies OB: refer to Black Box Warning of Codeine and other analgesics PharmD reports are included with tests: equivalent to private, individual Consult for each patient discussing drug – gene, drug –drug interactions with recommendations for alternatives. Financial Exposure to Patient: One-time, lifetime test for patient vs other routine tests such as CBCs that over a lifetime equal much more overall cost. Potential Rx savings on unnecessary drugs when precise dosing is achieved first time around. Weigh risk – benefit – one-time cost; peace of mind for patient and physician; better patient satisfaction and compliance, better outcome; less liability to physician.

Eliminate trial and error : “Right Drug, Right Dose, Right Indication, Right Patient, Right Time” Eliminate “One Size Fits All”medication management Enhance Patient Care Enhance Patient Satisfaction Enhance Compliance Risk Management : Reduce liability to physician

Higher than standard dosage required to achieve the desired results. Severe adverse drug reactions observed. Unexpected or unexplained response to medications. Multiple unsuccessful drug trials. Health issues in multiple organ systems. Multiple drug types prescribed. Patients with the following scenarios may benefit from PGT Simple screening questions of pain patients will offer to a provider enough information to make a “suspicious” or “probable” WDx of a genetic metabolic defect. If you had surgery or dental work, did you need extra anesthesia or pain medication? Have you taken hydrocodone? How did you feel after taking it? Did you get relief? Did you need higher than usual dosage? Are you allergic to medications? Do you regularly drink grapefruit, cranberry or pomegranate juice? Do you take herbal supplements?

Manufacturers recommend pharmacogenetic testing prior to or soon after initiation of therapy. FDA has also posted 16 drugs where it requires pharmacogenetic testing prior to prescribing htm

Cleveland Clinic Journal of Medicine, Volume 78, Number 4, April 2011

Inhibitor – A substrate(drug) that slows down or “inhibits” the metabolism of other substrates Inducer – A substrate that increase the elimination of other substrates Pro-drug – A substrate that is biologically inactive in its original (parent) form. These drugs must be metabolized (“activated”)before they are work in the body and produce their desired effect

Drug Metabolizing Phenotype Ultra Rapid Metabolizers ( UM ) Increased enzyme Extensive Metabolizers ( EM ) Normal Intermediate Metabolizers (IM ) Impaired Poor Metabolizers ( PM ) Non functional

Major CYP450 Isoforms 1. A2 6. 2D6 2. 2B6 7. 2E1 3. 2C8 8. 3A4 4. 2C A5 5. 2C A7

S Scenario #1- If a Physician group of 5 doctors performs 500 Paps/month with 75 biopsies & 20 $41 per biopsy and $60/IHC = $ 3, High Risk Pap $200/case = 14, TERC $140/case = 7, Urine $31/case = 6, Urine Feulgen $14/case = 2, UroVysion $56/case = 6,720 » Total Monthly PC Revenue$41,113 » Total Annual PC Revenue$493,356 » *Physician group must pay a local pathologist out of the PC revenue DNA Testing Custom Compounds

Eliminate trial and error: No more guess work “Right Dose, Right Drug, First Time, Every Time” Enhance patient care, Enhance patient satisfaction, Enhance patient compliance, Enhance patient confidence, Enhance patient outcome Private Consult with your patients on PharmD before prescribing Risk Management: Reduce liability to physician One Question Remains: You have reviewed the risks and benefits of implementing Pharmacogenetics Testing into your Medical Practice: Why Wouldn‘t You Begin Testing Your Patients Now?

Partnership Examples Scenario #2- If a Physician group of 10 doctors performs 1,000 Paps/month with 150 biopsies & 40 $41 per biopsy and $60/IHC = $ 7, High Risk Pap $200/case = 28, TERC $140/case = 15, Urine $31/case = 12, Urine Feulgen $14/case = 5, UroVysion $56/case = 13,440 Total Monthly PC Revenue$82,226 Total Annual PC Revenue$986,712 *Physician group must pay a local pathologist out of the PC revenue