1. Brad Esarey VP Business Operations

2. A need for Personalized Medicine

3. 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

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

5. ~60% of meds in top 20 list causing ADRs are linked to a genetic variation
122 drugs have FDA box warnings related to genetics

6. 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

7. 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)

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

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

10. 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

11. 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

12. 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)

13. 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

14. 14

15. 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 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

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

17. 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

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

19. 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

20. 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:
Confidential

21. 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):

22. 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

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

24. Application of Pharmacogenomics to Anti-platelet therapy

25. 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

26. Influence of CYP2C19 on Clopidogrel Response

28. Applications of PGx in Pain Management

29. 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

30. 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

31. 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

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

33. 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.

34. 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.

35. 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.

36. 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.

37. 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
% in Caucasians and Asians
14% in African Americans
29% in Ethiopians
Koren et al. Lancet 2006;368:704.

38. 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.

39. 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

40. 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

41. 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 patients tested
Educational lecture series and/or CME events as needed

42. 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

43. 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 – – CLIA License 18D

44. The Actual In-service

46. DON’T

47. 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

49. QUESTIONS?

50. THANK YOU!