1. Tailoring Medication to Patient Characteristics Farrokh Alemi, Ph.D. Georgetown University

2. Patent This presentation is based on a patent application on personalized medication held by George Mason University This presentation is based on a patent application on personalized medication held by George Mason University Scientists and government organizations have free access to this patent Scientists and government organizations have free access to this patent

3. Proposal Improve quality of care of rural veterans Improve quality of care of rural veterans Provide personalized advice on antidepressants Provide personalized advice on antidepressants

4. Case of George Military service Military service Industrial manager, polite, defines himself a “medieval knight.” Industrial manager, polite, defines himself a “medieval knight.” First depression episode at 26, treated with clomipramine, dose unknown. First depression episode at 26, treated with clomipramine, dose unknown. At 30 married with a daughter At 30 married with a daughter At 45 return of depressive symptoms, treated with fluvoxamine 200–300 mg and mirtazapine 15 mg At 45 return of depressive symptoms, treated with fluvoxamine 200–300 mg and mirtazapine 15 mg Depression continues, loss of interest in work, difficulty with bi-polar daughter Depression continues, loss of interest in work, difficulty with bi-polar daughter Loss of daughter, divorce and loss of work Loss of daughter, divorce and loss of work At 48, suicide At 48, suicide

5. First Treatment not Enough Who responds to SSRI citalopram? Highly educated Currently employed Caucasian women Few complicating psychiatric or medical disorders. At least 70% of patients did not respond. Beyond Efficacy: The STAR*D Trial. By Thomas R. Insel Am J Psychiatry. available in PMC 2006 September 30.

6. Medication Benchmarks: Selection of Antidepressants 70% not responsive 70% not responsive Six weeks before efficacy can be examined Six weeks before efficacy can be examined Sometimes 2-3 years searching for right medication Sometimes 2-3 years searching for right medication

7. What We Want? Tell me what works for me.

8. Rethinking Role of Data Patient data stored Data of others Patient data retrieved Care reminders Patient info displayed EHR Data warehousing Discovery Clinical Education Care Decisions

9. Rethinking Role of Data Patient data stored Data of others Patient data retrieved Patient info displayed EHR Data warehousing Discovery Clinical Education Care Decisions Care reminders Similar patients

10. Rethinking Role of Data Patient data stored Data of others Patient data retrieved Patient info displayed EHR Data warehousing Discovery Clinical Education Care Decisions Analytics: care forecasts Similar patients

11. Medication Benchmarks: Selection of Antidepressants Age Age Gender Gender Race Race Ethnicity Ethnicity Concurrent drugs Concurrent drugs Methadone Methadone Buprenorphine Buprenorphine Diet Diet Grapefruit Grapefruit Genetics Genetics CYP2D6 CYP2C19 CYP3A4 CYP1A2 Concurrent illness Concurrent illness Cancer Diabetes

12. Medication Benchmarks: Selection of Antidepressants Steps in Algorithm Steps in Algorithm 1. Select characteristics that make patient different from norm 2. Calculate similarity to patients in the database Based on GMU patent. Confidential communication

13. Medication Benchmarks: Selection of Antidepressants Steps in Algorithm Steps in Algorithm 1. Select characteristics that make patient different from norm 2. Calculate similarity to patients in the database Based on GMU patent. Confidential communication Number of features matched Features in one but not the other

14. Medication Benchmarks: Selection of Antidepressants Steps in Algorithm Steps in Algorithm 3. Reported average outcomes for different anti-depressants weighted by similarity of patients: Based on GMU patent. Confidential communication

15. Medication Benchmarks: Selection of Antidepressants Easy to implement Easy to implement 8 lines of SQL code 8 lines of SQL code Can work within any EHR Can work within any EHR Concurrent analysis Concurrent analysis No need to export data. No need for consent No need to export data. No need for consent No need to use data warehouses No need to use data warehouses No need to require same data on all patients No need to require same data on all patients

16. Medication Benchmarks: Selection of Antidepressants Easy to implement Easy to implement 8 lines of SQL code 8 lines of SQL code Can work within any EHR Can work within any EHR Concurrent analysis Concurrent analysis No need to export data. No need for consent No need to export data. No need for consent Current or warehoused data Current or warehoused data No need to require same data on all patients No need to require same data on all patients

17. Medication Benchmarks: Selection of Antidepressants Easy to implement Easy to implement 8 lines of SQL code 8 lines of SQL code Can work within any EHR Can work within any EHR Concurrent analysis Concurrent analysis No need to export data. No need for consent No need to export data. No need for consent Current or warehoused data Current or warehoused data No need to require same data on all patients No need to require same data on all patients

18. Data Source Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Sequenced Treatment Alternatives to Relieve Depression (STAR*D) 4,041 outpatients with non-psychotic depression 4,041 outpatients with non-psychotic depression 23 psychiatric and 18 primary care sites 23 psychiatric and 18 primary care sites 12-week course of the SSRI citalopram 12-week course of the SSRI citalopram Adjunct or replacement treatment in three subsequent phases Adjunct or replacement treatment in three subsequent phases

19. Technological Fix Technology is available Technology is available Data is available Data is available Analytical procedure is simple Analytical procedure is simple Will there be fewer George’s among us?