A Genotype-Guided Approach to Prescribing Psychiatric Drugs:...
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A Genotype-Guided Approach to Prescribing Psychiatric Drugs: Potential Benefits and Challenges

Pharma Tech Outlook | Tuesday, August 01, 2023

A genome-guided approach to drug treatment is not yet widely used in psychiatry. When replacing the traditional, treatment-as-usual approach, genotype-guided decisions on prescribing psychiatric drugs can improve treatment outcomes.

FREMONT, CA: Personal happiness, interpersonal harmony, and the capacity to contribute positively to society depend on good mental health. Mental diseases can result from physical health difficulties, discomfort, incapacity, or even death. They rank as the tenth highest cause of death in the United States and are among the most frequent causes of disability and associated suicide. Nineteen percent of all years of life lost in the United States due to disability and premature death are attributable to neuropsychiatric illnesses. Schizophrenia and depression are the two main mental illnesses impacting more than 300 million individuals worldwide.

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The breadth and nature of patients' responses to psychiatric medications vary greatly. This variation is brought about by nutritional, pathophysiological, environmental, and hereditary variables. The most significant of them are drug-drug interactions and variations in genetic makeup. Pharmacogenomic biomarkers can be developed from significant genetic variations for pharmacological treatment. They are mentioned by the FDA and serve as the foundation for the pharmacogenomic data that a doctor uses to customize drug therapy. These biomarkers are frequently employed in oncology, but psychiatry must adopt them.

Psychiatric pharmacogenomics's most recent advancements

It would be reasonable to anticipate that changing effective medication concentrations would coexist with a treatment efficacy effect of variant genes encoding the expression of drug-metabolizing enzymes. The subject of which genetic variations might be significant for choices about clinical treatment and dosage in psychiatric diseases has received much attention in the past.

In psychiatry, there has long been discussion on whether optimal drug exposure leads to optimal efficacy and improved tolerance. A recent meta-analysis that evaluated the dose-response curves for risperidone therapy discovered that the best antipsychotic treatment results are obtained at dosages of 3 to 5 mg/day of risperidone dose-equivalents. Similarly, fluoxetine dose equivalents of 20 and 40 mg/day result in the best antidepressant treatment outcomes. There are also available treatment ranges based on scientific research. Pre-emptive CYP genotyping might be utilized for precision dosage during treatment commencement, which is the crucial stage for symptom improvement in mental illnesses, ensuring optimal exposure to antipsychotics and antidepressants.

All commercially available pharmacogenetic techniques designed to enhance drug selection and dosing decisions in psychiatry look for significant CYP gene polymorphisms and rely on CYP genotypes to identify significant genetic variants. Consequently, pharmacogenomic recommendations based on CYP genotypes are included in dose recommendations from the FDA, the Clinical Pharmacogenetics Implementation Collaboration, and the Dutch Pharmacogenetics Working Group. For many psychiatric medications, the product characteristics summary includes special dosing instructions for the CYP2C19 and CYP2D6 genotypes based on genetic variance. The use of these pharmacogenomic drug labels in mental clinics can be increased. However, suggestions and instructions vary between sources and need to be harmonized.

Clinicians' resistance to altering their standard of care and ignorance of recent advances in pharmacogenomic research pose significant obstacles to using pharmacogenomic biomarkers in psychiatric clinics. This highlights the necessity of educating doctors and nurses on pharmacogenomics and the significance of effectively disseminating recent pharmacogenomics discoveries to encourage clinicians to think about pre-emptive genotyping.

Challenges and ethical issues

It is challenging to determine the cost-effectiveness of pre-emptive genotyping in psychiatry due to regional disparities in the price of laboratory pharmacogenetic testing and health care in general. Because the analyses solely focus on variations relevant to medication therapy, pharmacogenomically-based treatment individualization is advantageous for the patient and of no primary ethical concern. Although incidental discoveries of risk genes for specific diseases can occasionally result from whole-genome sequencing, this is rarely a problem when utilizing the specified commercial pharmacogenomic genotyping methods. Unfortunately, clinical laboratories undertaking pharmacogenomic analysis have yet to produce standards for handling accidental discoveries, unlike those developed for whole-exome or whole-genome sequencing. So, it's crucial to instruct clients and healthcare professionals.

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