1. SSRI Pharmacometabolomics Informed Pharmacogenomics Discovery and Translation Friday, February 21, 2014 Richard Weinshilboum, M.D. Dasburg Professor of Cancer Genomics Research Departments of Molecular Pharmacology & Experimental Therapeutics & Medicine Mayo Clinic College of Medicine Rochester, MN, USA American Society for Experimental NeuroTherapeutics | 16 th Annual Meeting

2. Disclosure AssureRx, 2008 Roche, 2010 Consultant, 2013 Consultant Invited Lecture Consultant American Society for Experimental NeuroTherapeutics | 16 th Annual Meeting All honoraria were donated to Mayo Foundation to support its research and education missions.

3. Learning Objectives To outline the power of pharmacometabolomics to “inform” pharmacogenomics To describe steps required to utilize pharmacogenomic DNA sequencing clinically American Society for Experimental NeuroTherapeutics | 16 th Annual Meeting

4. SSRI Pharmacometabolomics Informed Pharmacogenomics Discovery and Translation Introduction Pharmacometabolomics-informed PGx Sequencing and translation Conclusions

5. April 29, 2013 “In a few weeks the APA will release…DMS-5. Unlike our definitions of ischemic heart disease, lymphoma or AIDS, the DMS diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. Patients with mental illness deserve better.”

6. SSRI Pharmacogenomics and Pharmacometabolomics Variation in SSRI Therapeutic Outcomes and SSRIs as Molecular Probes for MDD Molecular Mechanisms

7. Mayo-NIH PGRN SSRI Pharmacogenomics Program

8. Mayo PGRN Citalopram-Escitalopram Clinical Trial

9. Mayo PGRN SSRI Clinical Trial Initial 529 Patients Ji et al., Pharmacogenomics J. 2013 Oct;13(5):456-63.

10. Mayo PGRN Citalopram-Escitalopram Clinical Trial Outcomes

11. SSRI Pharmacometabolomics Informed Pharmacogenomics Discovery and Translation Introduction Pharmacometabolomics-informed PGx Sequencing and translation Conclusions

12. Mayo PGRN Citalopram-Escitalopram Clinical Trial LCECA Metabolomics 918 patient samples (290 subjects, 3 timepoints) 37 LCECA metabolites assayed Dr. Wayne Matson, Bedford, MA

13. Mayo PGRN AMPS SSRI Metabolomics Study Plasma Serotonin

14. Serotonin Metabolism

15. Baseline Plasma Serotonin LCECA Metabolomics GWAS

16. Baseline Plasma Serotonin Locus Zoom, Chr 4

17. TSPAN5 Function

18. TSPAN5 Knockdown SK-N-BE(2) Neuroblastoma Cells

19. RBP-J Knockdown SK-N-BE(2) Neuroblastoma Cells

20. SSRI Pharmacometabolomics Informed Pharmacogenomics Discovery and Translation Introduction Pharmacometabolomics-informed PGx Sequencing and translation Conclusions

21. Mayo-NIH PGRN SSRI Pharmacogenomics Program

22. Pharmacogenomic Implementation Clinical utility Practice guidelines Genotyping-sequencing in CLIA-approved environment Data in EHR Pharmacy “alerts” Physician decision support software Insurance coverage Physician and patient acceptance

23. Pharmacogenomic Implementation Mayo eMERGE and the RIGHT Project Use PGRN-seq capture reagent for 84 “pharmacogenes”, 1013 local residents Sequence and place selected information in the EHR pre-emptively Alerts for selected drug-gene pairs Decision support software Pharmacy involvement A step toward whole gene sequencing

24. SSRI Pharmacometabolomics Informed Pharmacogenomics Discovery and Translation Introduction Pharmacometabolomics-informed PGx Sequencing and translation Conclusions

25. SSRI Pharmacogenomics and Pharmacometabolomics Pharmacogenomics ― Mayo PGRN SSRI Clinical Trial ― International SSRI Pharmacogenomics Consortium Pharmacometabolomics ― LCECA – assays complete, GWAS underway ― GC TOF MS – assays underway iPS Cells for Functional-Mechanistic Studies

26. SSRI Pharmacogenomics and Pharmacometabolomics Challenges MDD phenotypic heterogeneity Lack of MDD biomarkers or molecular classification Strategies Use the power of drugs as molecular probes Use of metabolomics—multiple platforms Use iPS cells for functional-mechanistic studies

27. April 29, 2013 “In a few weeks the APA will release…DMS-5. Unlike our definitions of ischemic heart disease, lymphoma or AIDS, the DMS diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. Patients with mental illness deserve better.”

28. Mayo PGRN SSRI Research Team Mayo PGRN Investigators David Mrazek, M.D. (PI)Meenal Gupta, Ph.D. Richard Weinshilboum, M.D. (PI)Balmiki Ray, MBBS Daniel Hall-Flavin, M.D. Yubo Chai, M.D., Ph.D. Yuan Ji, Ph.D. Scott Hebbring, Ph.D. Joanna Biernacka, Ph.D.Ryan Abo, Ph.D. David Katzelnick, M.D. Michelle Skime Julie Cunningham, Ph.D.Maureen Drews Jyotishman Pathak, Ph.D. Tony Batzler Greg Jenkins

29. Collaborators NIH Metabolomics Network Rima Kaddurah-Daouk, Ph.D. – Duke Oliver Fiehn, Ph.D. – UCD Wayne Matson, Ph.D. – BU Bedford VA RIKEN Center for Integrative Medical Science, Japan Michiaki Kubo, M.D., Ph.D. Taisei Mushiroda, Ph.D. University of Chicago Yusuke Nakamura, M.D., Ph.D. Indiana University School of Medicine Zeruesenay Desta, Ph.D.

30. David Mrazek, M.D.

31. Impact on Clinical Care and Practice Need for MDD biomarkers Pharmacometabolomics can “inform” pharmacogenomics DNA sequencing for pharmacogenomics is already moving into the clinic