Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
New Approach to Medicine: Personalized
Medicine/Pharmacogenetics/Pharmacogenomics
Bojana Stevich-Heemer, MS, PharmD, MEd, BCOP
Associate Professor - LECOM School of Pharmacy
9/22/2019
Required Disclosure
• The presenter for this activity has been required to
disclose all relationships with any proprietary entity
producing health care goods or services, with the
exemption of non-profit or government
organizations and non-health care related
companies.
• No significant financial relationships with
commercial entities were disclosed by any of the
speakers.
1.Pharmacogenetics has potential
to? (Select all that apply)
a. Improve patient outcome
b. Decrease risks of adverse events
c. Promote use of targeted cost-
effective therapy for patient care
2.Genomic medicine can help with which
of the following? (Select all that apply)
a. Disease risk stratification
b. Disease diagnosis
c. Disease prognosis
d. Selecting optimal therapy
e. Disease monitoring
3. Analytic validity is defined as?
a. Accuracy with which a specific
characteristic is identified in the
laboratory test
b. Accuracy with which a genetic test
identifies a specific clinical condition
c. Risk and benefits that result from genetic
test use
4. Which of the following is true about
reactive pharmacogenetic tests?
a. They are ordered when the new medication
is prescribed
b. Obtained for future use when needed in the
clinical setting
c. Also called prospective testing
5. The Genetic Information
Nondiscrimination Act of 2008 protects
from discrimination based on genetic
information in?
a. Health insurance only
b. Employment only
c. Health insurance and employment
d. Neither health insurance nor employment
• At the completion of this activity, the
participants will be able to:
• List indications for use of pharmacogenetics and
pharmacogenomics
• Describe major methods for evaluating evidence
for application of pharmacogenetics and
pharmacogenomics in the clinical practice
• Evaluate strengths of pharmacogenomics data
• Apply pharmacogenomics data for different
disease states
Objectives
Objective: List indications for use of
pharmacogenetics and
pharmacogenomics
• Personalized/precision medicine: right
treatment to the right person at right dose with
maximizing efficacy and minimizing toxicity
• Pharmacogenetics: the study of variability in
drug response due to genetics; relation to
genes which determine drug metabolism
• Pharmacogenomics: broad term which includes
all genes in the genome that may determine
drug response
Personalized Medicine, Pharmacogenetics,
and Pharmacogenomics
• Pharmacogenetics/pharmacogenomics can
target genes that are involved in drug:
• Metabolism
(pharmacokinetic/pharmacodynamics)
• Binding and/or interfering with different
cellular process
Pharmacogenetics/Pharmacogenomics
• Pharmacogenetics uses genetic information to
improve clinical outcomes of pharmacotherapy
• Pharmacogenetics has potential to:
• Improve patient outcomes
• Decrease risks of adverse event
• Promote use of targeted cost-effective therapy
for patient care
Pharmacogenetics in Clinical Settings
Klein ME et. al. Journal of Pharmaceutical Sciences 106. 2017. 2368-2379
• According to the National Human Genome
Research Institute genomic medicine is defined
as:
“Emerging medical discipline that involves
using genomic information about an individual
as part of their clinical care (e.g. for
diagnostic of therapeutic decision-making)
and the health outcomes and policy
implications of that clinical use”
Genomic Medicine
National Human Genome Research Institute at: www.genome.gov/27527652/genomic-medicine-and-health-
care/
• Genomic medicine: individual patient’s genotypic information in his or her clinical care
• Includes both Mendelian and multigenic complexes diseases
• Currently genomic focuses more on single Mendelian variants with large effect
• Expected that genomics soon should change to using at the same time numerous variants
Genomic Medicine Definitions
Manolio et. al. Genetic in Medicine 2013. 15(4): 258-267
• Some examples of genomic medicine projects
which are currently being implemented in
clinical practice include:
• Tumor-based genotype-driven treatment
• Risk/susceptibility testing in relatives of patients
with mutation-bearing cancer
• E.g.BRCA1 and BRCA2 mutations
• CYP2C19 and antiplatelet therapy
Genomic Medicine Projects Currently
In Implementation
Manolio et. al. Genetic in Medicine 2013. 15(4): 258-267
• Genomic Medicine can help:
• Disease Risk Stratification
• Disease Diagnosis
• Disease Prognosis
• Selecting Optimal Therapy
• Disease Monitoring
Genomic Medicine
Goodman DM. et.al. JAMA 2013. Vol 309 No. 14 p. 1544
• BRCA1 and BRCA2 Gene Mutations:
• One of the best known and most widely discussed genetics test ever
• Overall, women have 12% lifetime risk of developing breast cancer
• Women with BRCA1 mutation have increased risk of developing breast cancer
• Women with BRCA2 mutation have increased risk of developing breast cancer
Disease Risk Stratification
National Cancer Institute at: www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet
• BRCA1 and BRCA2 Gene Mutations:
• Overall about 1.3% women will develop
ovarian cancer
• Estimated that 44% of women with BRCA1
mutation will develop ovarian cancer
• Estimated that 17% of women with BRCA2
mutation will develop ovarian cancer
Disease Risk Stratification
National Cancer Institute at: www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet
• BRCA1 and BRCA2 Gene Mutations:
• Men with BRCA1 and BRCA2 mutations also
have an increased risk of breast cancer
• Men with BRCA1 and BRCA2 mutations also
have an increased risk of prostate cancer
Disease Risk Stratification
National Cancer Institute at: www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet
• Diagnostic testing: using test to confirm the presence or absence of a disease
• Before the era of genomic medicine diagnosis was usually based on:
• Patient’s age
• Clinical features
• Laboratory test
• Imaging studies
Disease Diagnosis
• DNA Single-Gene Tests:
• RAS regulates cell growth and regulation
• RAS has three isoforms with KRAS most
commonly mutated
• KRAS mutated in 30%-50% of colon cancers
and is associated with:
• Shorter survival
• More aggressive tumors
Disease Prognosis
• DNA Single-Gene Tests:
• Ability to define distinct subgroups within a disease improves ability to use targeted therapies
• Example includes Cystic Fibrosis (CF):
• CFTR gene gives instructions for making a protein called the cystic fibrosis transmembrane conductance regulator
• Cystic fibrosis transmembrane conductance regulator functions as a channel across the membrane of cells which produce mucus, sweat, saliva, etc.
Selecting Optimal Therapy
U.S. National Library of Medicine at: www.ghr.nlm.nih.gov/gene/CFTR
• DNA Single-Gene Tests:
• Example includes Cystic Fibrosis (CF):
• Mutations in CFTR gene (e.g. E56K, P67L,
G551D, and some others) → Impaired chloride
channel function
• Novel small molecule, ivacaftor improves
function of specific mutations in CFTR and
patient outcome
Selecting Optimal Therapy
Kalydeco (ivacaftor) Tablets and Oral Granules Package Insert
• The risk of rejection with transplant:
• Highest in the early period immediately after transplant
• Declines over time
• Never goes away
• With cardiac and renal transplant need to do invasive biopsies to identify graft dysfunction
Disease Monitoring
• Potentially available less invasive
procedure, RNA profiling of:
• Peripheral blood for cardiac transplant
• Urine in kidney transplant
• RNA profiling technique allows to identify a
key set of transcripts to detect rejection of
transplanted grafts
Disease Monitoring
Horwitz PA. et.al. Circulation. 2004. 110:3815-3821
Li B et. al. N Engl Med. 2001. Vol. 344, No.13. 947-954.
Objective: Describe major methods
for evaluating evidence for
application of pharmacogenetics and
pharmacogenomics in the clinical
practice
• Criteria for evaluating genetic and
genomic tests include:
• Analytical validity
• Clinical validity
• Clinical utility
Evidence Supporting Clinical
Implementation of Pharmacogenomics
Holtzman NA , Watson MS. Final Report of the Task Force on Genetic Testing. Baltimore: Johns
Hopkins University Press: 1999. Promoting Safe and Effective Genetic Testing in the United States
• “Analytic validity: accuracy with which a particular
genetic characteristic can be identified in a laboratory
test” (Burke W et. al., 2002)
• Can use different protocols to test most genetic
characteristics of clinical interest
• There can be different technical issues when evaluating
analytic validity such as:
• Specific technical requirements for chosen assay
• The reliability of assay
• How much reliability varies from laboratory to laboratory
Analytical Validity
Burke W. et.al. Am J Epidemiol 2002. Vol.156 No.4 311-318
Burke W. Curr Protoc Hum Genet. 81:9.15.1-9.15.8
• Two different types of genetic tests:
• In-house: test by clinical laboratory (e.g.
laboratory-developed or home-grown)
• Manufacturer-developed: in vitro diagnostic
test for a specific drug that is critical for
safe and effective use of that drug (e.g.
companion diagnostic tests)
Analytical Validity
• The Clinical Laboratory Improvement Amendments (CLIA) governs quality standards for laboratory-developed tests
• CLIA regulations classifies laboratory testing based on the complexity of the tests as either:
• Waived or
• Non-waived → Molecular genetic testing is high-complexity
• Genetic test will not be used if it does not meet acceptable standards for analytic validity
Analytical Validity
Clinical Laboratory Improvement Amendments at: http://www.cms.hhs.gov/clia
• “Clinical validity: accuracy with which a
genetic test identifies a paricular clinical
condition” (Holtzman NA, Watson MA, 1999)
• Clinical validity is described by:
• Sensitivity
• Specificity
• Positive predictive value
• Negative predictive value
Clinical Validity
Burke W. Curr Protoc Hum Genet. 81:9.15.1-9.15.8
Holtzman, NA; Watson, MS. Final Report of the Task Force on Genetic Testing. Baltimore: Johns Hopkins University
Press: 1999. Promoting safe and effective genetic testing in the United States
• Sensitivity: among people with a particular
condition the proportion who have positive
test
• Specificity: among people who do not have
condition the proportion who have negative
test
• Positive predictive value
• Negative predictive value
Clinical Validity
Burke W. Curr Protoc Hum Genet. 81:9.15.1-9.15.8
• Positive predictive value: among people
with positive test the proportion who have
the condition
• Negative predictive value: among people
with negative test the proportion who have
the condition
Clinical Validity
Burke W. Curr Protoc Hum Genet. 81:9.15.1-9.15.8
• “Clinical utility: refers to the likelihood that the test will lead to an improved health outcome” (Burke et.al. 2002)
• The most important factors in determining clinical utility include:
• If the test or subsequent interventions lead to improved health outcomes in people with positive test result
• What risks happen as a result of testing
Clinical Utility
Burke W. et.al. Am J Epidemiol 2002. 156-311-318
Burke W. Curr Protoc Hum Genet. 2015. 81:9.15.1-9.15.8
• To completely measure clinical utility need to
include:
• Medical outcomes
• Social outcomes
• Subsequent interventions for peoples with
positive and negative test results
Clinical Utility
Burke W. Curr Protoc Hum Genet. 81:9.15.1-9.15.8
Objective: Evaluate strengths of
pharmacogenomics data
• Evaluation of drug-gene association should
include:
• Genetic variants of interest
• Evidence to support clinical utility
• Evidence-based guidelines (e.g. Clinical
Pharmacogenetic Implementation Consortium
guidelines with clear recommendation)
Drug-Gene Association
Arwood MJ et. al. Clin Transl Sci 2016. 9, 233-245
• Pharmacogenetic testing can be
performed:
• Reactively (at point-of-care):
• At the point of care to guide drug therapy or
• Pre-emptively (prospective):
• Obtained for future use when needed in
clinical setting
Pharmacogenetic Test Ordering and
Laboratory Processing
• Reactive/Point-of-Care Pharmacogenomic
Testing:
• Ordered when new medication is prescribed
• Pharmacogenomic test can be ordered for the
specific gene or genes that are involved in drug
metabolism, transport and/or target
• Delay in therapy until results are back
• Would still need interim medication
Point-of-Care vs. Preemptive/Prospective
Pharmacogenomic Testing
Haga SB and Moaddeb J. Pharmacogenet Genomics 2014. 24(3): 139-145
• Preemptive/Prospective Pharmacogenomic Testing:
• Involves analysis of a panel of genes with known associations to drug outcome
• Some populations may specifically benefit from pre-emptive testing such as populations with:
• Chronic conditions
• Risk factors for chronic conditions
• Preemptive pharmacogenomic tests results available whenever treatment is needed
Point-of-Care vs. Preemptive/Prospective
Pharmacogenomic Testing
Haga SB and Moaddeb J. Pharmacogenet Genomics 2014. 24(3): 139-145
• Growing list of drugs that have some reference to pharmacogenomic testing included in the drugs labeling
• Germline mutations (e.g. CYP metabolizing enzyme gene variations)
• Somatic mutations (e.g. KRAS expression in colorectal cancer)
• Some drugs are co-developed with pharmacogenetic tests
Challenges Associated with Producing
Evidence
• Most labels refer to reported pharmacogenetic
associations (e.g. altered drug metabolism or
drug-gene interactions)
• Most labels do not specifically recommend
testing before prescribing a drug or provide any
recommendation how prescribing should be
modified
Challenges Associated with Producing
Evidence
• Very important to develop clinical practice
guidelines for pharmacogenomics
• Major pharmacogenomics guidelines:
• The Clinical Pharmacogenetic Implementation
Consortium (CPIC), established 2009
Synthesizing Evidence-Based
Guidelines
Clinical Pharmacogenetics Implementation Consortium Guidelines at: www.cpicpgx.org/guidelines/
• The Clinical Pharmacogenetic Implementation
Consortium (CPIC):
• Formed by joint effort between the Pharmacogenomics
Knowledge Base (PharmGKB) and the National Institute
of Health (NIH)-funded Pharmacogenomics Research
Network
• Created to develop guidelines that would enable
translation of clinically relevant pharmacogenetic test
results into accountable therapeutic recommendation
• Provide guidance to clinicians how available genetic
test results should be used to improve drug therapy
Evidence-Based Guidelines
Clinical Pharmacogenetics Implementation Consortium: https://cpicpgx.org/
• The Clinical Pharmacogenetic Implementation
Consortium (CPIC):
• Genes-Drugs: CPIC assigns CPIC levels to
genes/drugs with:
• PharmGKB Clinical Annotation Levels of Evidence
• PharmGKB PGx level for FDA-approved drug labels
• Based on nomination to CPIC for consideration
Evidence-Based Guidelines: Evaluating
Strengths of Pharmacogenomics Data
Clinical Pharmacogenetics Implementation Consortium: https://cpicpgx.org/genes-drugs/
Evidence-Based Guidelines: Evaluating
Strengths of Pharmacogenomics Data
PharmGKB Clinical Annotation Levels of Evidence
1A Gene/drug pairs have sufficient evidence for at least one
prescribing action to be recommended
1B Gene/drug pairs have sufficient evidence for at least one
prescribing action to be recommended
2A Gene/drug pairs have sufficient evidence for at least one
prescribing action to be recommended
2B Gene/drug pairs have sufficient evidence for at least one
prescribing action to be recommended
3 Not considered to have adequate evidence or actionability to
have prescribing recommendations
4 Not considered to have adequate evidence or actionability to
have prescribing recommendations
Clinical Pharmacogenetics Implementation Consortium: https://www.pharmgkb.org/page/clinAnnLevels
• PharmGKB PGx level for FDA-approved drug labels
of:
• Genetic testing required
• Genetic testing recommended
• Actionable
• Informative
• Based on nomination to CPIC for consideration
Evidence-Based Guidelines: Evaluating
Strengths of Pharmacogenomics Data
Clinical Pharmacogenetics Implementation Consortium Guidelines at: www.cpicpgx.org/guidelines/
• Guidelines need to be disseminated at:
• Peer reviewed journals
• Web sites
• National guidelines site
Clinical Practice Dissemination
• Selecting gene-drug pairs for implementation
• Institutional oversight of pharmacogenetic evidence
analysis and application to patient care
• Clinical support for health care providers
• Standardized laboratory ordering and interpretation
procedures
• Involvement of informational technology
• Education of different health care professionals
• Quality improvement and economic evaluations
Main Characteristics of Clinical
Pharmacogenetics Services
Arwood MJ et. al. Clin Transl Sci 2016. 9, 233-245
Need to obtain support from institutional leadership
Generally should obtain support from:
Administration
Medicine
Pharmacy
Laboratory
Health informational technology (IT)
Administrative and Stakeholder
Engagement
Arwood MJ et. al. Clin Transl Sci 2016. 9, 233-245
• Informational technology
• Scientific
• Education
• Ethical, legal, social and regulation issues
• Reimbursement
Major Barriers to the Clinical
Implementation of Pharmacogenetics
Klein ME et. al. Journal of Pharmaceutical Sciences 106. 2017. 2368-2379
• Some of potential barriers to the clinical
implementation of pharmacogenomic testing
include:
• Test-related barriers
• Knowledge barriers
• Evidence barriers
Barriers to the Clinical Implementation
of Pharmacogenomic Testing
Johnson JA. Pharmacogenomics. 2013. 14(7): 835-843.
• Many challenges in implementation of genomics
in clinical practice:
• Limited evidence
• Conflicting interpretation of benefit and value
• Limited access to genomic medicine expertise
and testing
• Lack of standards for genomic applications
• Lack of research funding and reimbursement
Challenges In Implementation of
Genomics in Clinical Practice
Manolio et. al. Genetic in Medicine 2013. 15(4): 258-267
• Clinical pharmacogenetics implementation can
be incorporated into electronic health record
(EHR)
• EHR can help health care providers to easily
and quickly interpret and act on
pharmacogenetic test results
Clinical Pharmacogenomics
Implementation
Arwood MJ et. al. Clin Transl Sci 2016. 9, 233-245
• Need comprehensive and multidisciplinary
strategies to educate different health care
professionals
• Genetics/Genomics Competency Center (G2C2)
established to provide high quality
genetics/genomics educational resources for
health care educators and practitioners
Educational Needs to Support
Implementation of Pharmacogenomics
Arwood MJ et. al. Clin Transl Sci 2016. 9, 233-245
National Human Genome Research Institute at: www.genomicseducation.net
• Genetics/Genomics Competency Center
(G2C2) has competencies map for:
• Nursing
• Physician assistant
• Pharmacist
• Genetic counselors
• Physicians
Educational Needs to Support
Implementation of Pharmacogenomics
National Human Genome Research Institute at: www.genomicseducation.net
• Genetics/Genomics Competency Center (G2C2) competency map for pharmacists include:
• Basic genetic concepts
• Genetic and diseases
• Pharmacogenetics/pharmacogenomics
• Ethical, legal and social implications
Educational Needs to Support
Implementation of Pharmacogenomics
National Human Genome Research Institute at: www.genomicseducation.net
• The Genetic Information Nondiscrimination Act
(GINA) of 2008 protects from discrimination
based on their genetic information in both:
• Health insurance (Title I) and
• Employment (Title II)
The Genetic Information
Nondiscrimination Act of 2008
National Human Genome Research Institute at: www.genome.gov/10001740/ethical-legal-and-social-
issues-in-genomic-medicine
• Informed consent: a process for getting permission
before conducting a healthcare intervention on a
person
• A health care provider may ask a patient to consent
to receive therapy before providing it or a clinical
researcher may ask a research participant before
enrolling that person into a clinical trial
Informed Consent and Patient-Provider
Communication
• Different factors should be taken into considerations when designing an informed consent process and consent form such as:
• Information is personal and unique to each individual
• If information is going to be stored and used indefinitely
• Need to inform individuals about susceptibility to a broad range of conditions (some of which are unexpected given personal or family history)
• If tests carry with them risks that are uncertain or unclear
• Raise privacy concerns (due to the risk of re-identification)
Informed Consent for Pharmacogenomics
National Human Genome Research Institute at: https://www.genome.gov/about-genomics/policy-
issues/Informed-Consent
FDA Drug Labels and Pharmacogenomics
U.S. Food and Drug Administration at: www.fda.gov/drugs/scienceresearch/ucm572698.htm
• Drug labeling may include information on
genomic biomarkers which can define:
• Drug exposure and clinical response variability
• Risk for adverse events
• Genotype-specific dosing
• Mechanisms of drug action
• Polymorphic drug target and disposition genes
• Trial design
Objective: Apply
pharmacogenomics data for
different disease states
• Psychiatry
• Cardiology
• Neurology
• Infectious diseases
• Hematology/Oncology
• Pulmonology
• Anesthesiology
• Gastroenterology
Pharmacogenomics Data for Different
Disease States
U.S. Food and Drug Administration at: www.fda.gov/drugs/science-research-drugs/table-
pharmacogenomic-biomarkers-drug-labeling
• Oncology has the most success in search for
useful biomarkers
• With the success of targeted therapies there is
a huge interest in finding more biomarkers to
help to identify patients with the greatest
likelihood of receiving benefits from a specific
therapy
Pharmacogenomics in Oncology Research
• In pharmacogenomics research in
oncology very important both:
• Somatic mutations and
• Germline mutations
Pharmacogenomics in Oncology
Research
Wheeler HE et. al. Nat Rev Genet. 2013. 14(1): 23-34
• Somatic mutations: present in the cancer
tissue and can define cancer subtype
• Can develop medications that target specific
receptor expressed on the cancer cell
• Examples include: Monoclonal antibodies
panitumumab and cetuximab directed
against the epidermal growth factor receptor
(EGRF)
Pharmacogenomics in Oncology Research
Wheeler HE et. al. Nat Rev Genet. 2013. 14(1): 23-34
• Germline mutations:
• Present in patient’s normal tissues
• Affect pharmacokinetics and pharmacodynamics
of a medication
• Example include: Mercaptopurine used for the
treatment of acute lymphoblastic leukemia (ALL)
• Patients with inactive variant of TPMT allele need
to have mercaptopurine dose reduced due to the
increased toxicity
Pharmacogenomics in Oncology Research
Wheeler HE et. al. Nat Rev Genet. 2013. 14(1): 23-34
1.Pharmacogenetics has potential
to? (Select all that apply)
a. Improve patient outcome
b. Decrease risks of adverse events
c. Promote use of targeted cost-
effective therapy for patient care
2.Genomic medicine can help with which
of the following? (Select all that apply)
a. Disease risk stratification
b. Disease diagnosis
c. Disease prognosis
d. Selecting optimal therapy
e. Disease monitoring
3. Analytic validity is defined as?
a. Accuracy with which a specific
characteristic is identified in the
laboratory test
b. Accuracy with which a genetic test
identifies a specific clinical condition
c. Risk and benefits that result from genetic
test use
4. Which of the following is true about
reactive pharmacogenetic tests?
a. They are ordered when the new medication
is prescribed
b. Obtained for future use when needed in the
clinical setting
c. Also called prospective testing
5. The Genetic Information
Nondiscrimination Act of 2008 protects
from discrimination based on genetic
information in?
a. Health insurance only
b. Employment only
c. Health insurance and employment
d. Neither health insurance nor employment
• Arwood MJ, Chumnumwat S, Cavallary LH, Nutescu EA and Duarte JD. Implementing Pharmacogenomics at Your Institution: Establishment and Overcoming Implementation Challenges. Clinical and Translational Sciences 9, 2016. 233-245. doi:10.1111/cts.12404
• Burke W, Austin MA, Gwinn M, Guttmacher A, Haddow J…Wiesner GL. Genetic Test Evaluation: Information Needs of Clinicians Policy Makers, and the Public. American Journal of Epidemiology. Vol. 165, No. 4 311-318. doi:10.1093/aje/kwf055
• Burke W. Genetic Test: Clinical Validity and Utility. Curr Protoc Hum Genet. 81:9.15.1-9.15.8. doi: 10.1002/0471142905.hg0915s81
• Clinical Pharmacogenetics Implementation Consortium: https://cpicpgx.org/ Accessed: 7/30/2019.
• Clinical Pharmacogenetics Implementation Consortium: https://cpicpgx.org/genes-drugs/Accessed: 7/30/2019.
• Clinical Pharmacogenetics Implementation Consortium: https://www.pharmgkb.org/page/clinAnnLevels Accessed: 7/30/2019.
• Clinical Pharmacogenetics Implementation Consortium Guidelines at: https://cpicpgx.org/guidelines/ Accessed: 7/30/2019.
• Clinical Laboratory Improvement Amendments at: http://www.cms.hhs.gov/clia Accessed: 7/30/2019.
• Goodman DM, Lynm C, Livingston EH. Genomic Medicine. JAMA (The Journal of American Medical Association). 2013. 309(14):1544
• Haga SB, Moaddeb J. Comparison of Delivery Strategies for Pharmacogenetic Testing Services. Pharmacogenet Genomics. 2014. 24(3): 139-145. doi:10.1097/FPC.0000000000000028
References
• Holtzman, NA; Watson, MS. Final Report of the Task Force on Genetic Testing.
Baltimore: Johns Hopkins University Press: 1999. Promoting safe and effective
genetic testing in the United States
• Horwitz PA, Tsai EJ, Putt ME, Gilmore JM, Lepore JJ...Cappola TP. Detection of
Cardiac Allograft Rejection and Response to Immunosuppressive Therapy With
Peripheral Blood Gene Expression. Circulation. 2004. 110:3815-3821. doi:
10.1161/01.CIR.0000150539.72783.BF
• Johnson JA. Pharmacogenomics in clinical practice: how far have we come and
where are we going? Pharmacogenomics. 2013. 14(7): 835-843. doi:10.2217/pgs.
13.52.
• Kalydeco Package Insert. Boston, MA. Vertex Pharmaceutical Incorporated; April
2019.
• Klein ME, Parvez MM, Shin JG. Clinical Implementation of Pharmacogenomics for
Personalized Precision Medicine: Barriers and Solutions. Journal of Pharmaceutical
Sciences. 2017. 106. 2368-2379. doi: 10.1016/j.xphs.2017.04.051
• Li B, Hartono C, Ding R, Sharma VK, Ramaswamy R….Suthanthiran M. Noninvasive
Diagnosis of Renal-Allograft Rejection by Measurement of Messenger RNA for
Perforin and Granzyme B in Urine. The New England Journal of Medicine. 2001.
Vo. 344, No.13. 947-954.
References
• Manolio TA, Chisholm RL, Ozenberger B, Roden DM, Williams MS…Ginsburg GS.
Implementing genomic medicine in the clinic: the future is here. Genetic in Medicine.
2013. Vol 15, Number 4, 258-267. doi:10.1038/gim.2012.157
• National Cancer Institute at: www.cancer.gov/about-cancer/causes-
prevention/genetics/brca-fact-sheet Accessed: 7/30/2019.
• National Human Genome Research Institute at: www.genome.gov/27527652/genomic-
medicine-and-health-care/ Accessed: 7/30/2019.
• National Human Genome Research Institute at: www.genomicseducation.net
• National Human Genome Research Institute at: www.genome.gov/10001740/ethical-
legal-and-social-issues-in-genomic-medicine Accessed: 7/30/2019.
• National Human Genome Research Institute at: https://www.genome.gov/about-
genomics/policy-issues/Informed-Consent Accessed: 7/30/2019.
• U.S. Food and Drug Administration at:
www.fda.gov/drugs/scienceresearch/ucm572698.htm Accessed: 7/30/2019.
• U.S. Food and drug Administration at: www.fda.gov/drugs/science-research-
drugs/table-pharmacogenomic-biomarkers-drug-labeling Accessed: 7/30/2019.
• U.S. National Library of Medicine at: www.ghr.nlm.nih.gov/gene/CFTR Accessed:
7/30/2019.
• Wheeler HE, Maitland ML, Dolan ME, Cox NJ, Ratain MJ. Cancer pharmacogenomics:
strategies and challenges. Nat Rev Genet. 2013. 14(1): 23-34 doi: 10.1038/nrg3352.
References