What is pharmacogenomics?

Some of us respond differently to the same medications that we take, or we may experience different side-effects from drugs. The way we respond can be due to the genes we have inherited. With respect to drugs, our unique genetic make-up and our individual response may mean that a drug that is effective for one person may be less effective for another or that a drug that is safe for one person may be less safe for another person—even at the same dosage.

Most drugs are broken down (metabolized) in the body by various enzymes. In some cases, an active drug is made inactive (or less active) through metabolism. In other cases, an inactive (or less active) drug is made more active through metabolism. The challenge in drug therapy is to make sure that the active form of a drug stays around long enough at the right level to do its job. However, some people have variable enzyme action so that they may metabolize the drug too quickly or too slowly or not at all — meaning that the drug may not produce its intended effect or it may remain in a person's system too long and may lead to side effects.

Individual response to a drug may also be related to variability in the drug target, for example a protein that the drug binds to in order to produce its specific effect. Furthermore, individuals may experience side-effects (known as hypersensitivity reactions) from certain medications due to variability in proteins involved in the immune response.

Pharmacogenomics is the study of genetic variability that causes individual responses to medications. By analyzing the genes that produce the specific drug targets or enzymes that metabolize a medication or are associated with immune response, a doctor may decide to raise or lower the dose or even change to a different drug. The decision about which drug to prescribe may also be influenced by other drugs the person is taking, in order to avoid drug-drug interactions.

The terms "pharmacogenomics" and "pharmacogenetics" are often used interchangeably.
 

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Why is pharmacogenomics important?

When initiating drug therapy to treat a particular condition, doctors typically prescribe one of several appropriate drugs. Dosages and timing of drugs are usually based upon the anticipated rate of metabolism and clearance from the body in the average person. They prescribe a "standard" dose based on factors such as weight, sex, and age. Clinically, however, each person responds uniquely to treatment and doctors must make adjustments. For example, the doctor may adjust the drug dose or switch to a different therapy, depending on whether the person's condition is responding to the medication and whether the individual is experiencing unpleasant or dangerous side effects. Sometimes a person may find that a treatment that has been working well for them suddenly causes symptoms when they start taking an additional drug.

The concentrations or effects of some drugs are monitored with blood tests and the drug dosages may be increased or decreased to maintain the drug level in an established therapeutic range. Follow-up of drug concentration is called "therapeutic drug monitoring." If changing the drug dose is not effective in treating or controlling the person's condition, or the person still has side effects, then the person may be given a different drug.

In contrast, pharmacogenomics offers physicians the opportunity to individualize drug therapy for people based on their genetic make-up. Testing people prior to initiating drug therapy to determine their likely response to different classes of drugs is an emerging area of testing. Such genetic information could prove useful to both the doctor and patient when choosing current and future drug therapies and drug doses. For certain medications, pharmacogenomics is already helping physicians predetermine proper therapies and dosages to have a better chance of achieving the desired therapeutic effect while reducing the likelihood of adverse effects.

 

How does pharmacogenomic testing work?

Genes are the basic units of genetic material, the segments of DNA that usually code for the production of specific proteins, including the proteins known as enzymes. Each person has two copies of most genes: one copy is inherited from their mother and one copy is inherited from their father. Each gene is made up of a specific genetic code, which is a sequence of nucleotides. Each nucleotide can be one of four different nucleotides (A, T, G, or C). For each nucleotide position in the gene, one of the four nucleotides is the predominant nucleotide in the general population. This nucleotide is usually referred to as "wild type." If an individual has a nucleotide that is different from "wild type" in one copy of their genes, that person is said to have a heterozygous variant. If an individual has the same variant nucleotide in both copies of their genes, that person is said to have a homozygous variant.
Nucleotide or genetic variants (also called polymorphisms or mutations) occur throughout the population. Some genetic variants are benign — do not produce any known negative effect, or may be associated with features like height, hair colour, and eye colour. Other genetic variants may be known to cause specific diseases. Other variants may be associated with variable response to specific medications.

Pharmacogenomic tests look for genetic variants that are associated with variable response to specific medications. These variants occur in genes that code for drug-metabolizing enzymes, drug targets, or proteins involved in immune response. Pharmacogenomic tests have the ability to determine if a variant is heterozygous or homozygous, which can impact an individual's response or reaction to a drug.
 

When are the tests ordered?

A doctor may test a patient's genes for certain variations that are known to be involved in variable response to a medication prior to treatment, during the initial phase of treatment, or later in the treatment. The results of the testing may be combined with the individual's clinical information, including age, weight, health and other drugs that they are taking, to help individualise therapy. Sometimes, the doctor may use this information to adjust the medication dose or sometimes to choose a different drug. Pharmacogenomic testing is intended to give the doctor additional information but usually does not replace the need for therapeutic drug monitoring.

Pharmacogenomic testing for a specific gene is only performed once since a person's genetic makeup does not change over time. Depending on the medication, a single gene may be ordered or multiple genes may be ordered. An example of a medication for which multiple genes are usually evaluated is warfarin, which can be affected by genetic variation in CYP2C9, CYP4F2, CYP2C cluster and VKORC1.

Testing may be ordered prior to starting specific drug therapies or if a person who has started taking a drug is experiencing side effects or having trouble establishing and/or maintaining a stable dose. Sometimes a person may not experience such issues until other medications that affect the metabolism or action of the drug in question are added or discontinued.

 

The Pharmacogenomic Tests

There are currently a variety of pharmacogenomic tests that can be ordered on a clinical basis. Some tests may only be applicable to specific ethnic groups. The following are some drugs for which pharmacogenomic tests are available:

DRUG associated diseases/conditions gene(s) tested
Warfarin Excessive clotting disorder CYP2C9, CYP4F2, CYP2C cluster and VKORC1 
Thiopurines (azathioprine, mercaptopurine and thioguanine) Autoimmune/childhood leukaemia

Post-transplatation, chronic inflammatory bowel disease, inflammatory joint disease.
TPMT
Clopidogrel Cardiovascular CYP2C19
Irinotecan Cancer UGT1A1
Abacavir HIV HLA-B*5701
Carbamazepine, phenytoin Epilepsy HLA-B*1502
Some antidepressants, some antiepileptics, some anti-cancer drugs Psychiatric, Epilepsy, Cancer CYP2D6, CYP2C9, CYP2C19, DPYD

Is there anything else I should know?

For most medications, the potential benefit of pharmacogenomic tests are yet to be established. However, they may be important when the medication of interest has a narrow therapeutic range and/or is associated with a high rate of adverse events.

Pharmacogenomic tests are intended to provide the doctor and patient with additional information when selecting drug treatments and dosages. There are potential implications for a family member, patients may want to consult with a genetic counsellor prior to and after having a pharmacogenomic test performed. Genetic counselling and informed consent are recommended for all genetic testing.

To learn more about the role of pharmacogenomics in personalized medicine, visit the Personalized Medicine Coalition website.
 

Common Questions
  • Should everyone have pharmacogenomic tests performed? Currently they are only indicated if a person is going to take, or is taking, a drug that has an accepted pharmacogenomic test associated with it.
  • Why am I only tested once? Your genetic make-up does not change over time. You may, however, have other pharmacogenomic tests performed if you take a different drug with a different associated pharmacogenomic test.
  • Does this mean my drug levels do not have to be monitored? No. Since there are other factors that affect drug levels besides your genetics, therapeutic drug monitoring may still be necessary.
  • What type of sample is used? A blood sample is obtained by inserting a needle into a vein in the arm. Saliva samples and buccal swabs, collected by brushing the inner side of the cheek with a swab, can also be used.
  • How do pharmacogenomic tests differ from genetic tests? Pharmacogenomic tests are performed to evaluate a person's potential response to a drug therapy. Most genetic tests have been developed to help diagnose or predict the development of a genetic disease, or to detect bacteria and viruses, for forensic medicine purposes, and in establishing parentage.
  • Will I be monitored differently after the test? You may be monitored differently depending on the results of the test, especially when starting the medication, changing the dose, or when adding or discontinuing another medication.
  • Should other family members be tested? This is a question to discuss with your doctor and your family members. In some cases it may be useful; in others it may only be relevant if they are going to be taking the same drug or a drug in the same class. Pharmacogenomic test results are useful information for a family member to share with the doctor along with the family's medical history.
  • How do I know whether or not I should have testing done? You and your doctor should consider the condition that you have, your history of drug-related side effects and/or adverse drug reactions, the drug therapies that are available, and the uses the test is intended for. Pharmacogenomic tests are not meant to stand alone but are meant to be used in conjunction with your other clinical findings.
Related Pages
On this site
Tests: TPMT

Need to learn more about genetics?
Genetic basics with video and illustrations
Genetic testing in-depth article 

Elsewhere on the Web
National Institutes of Health: Medicines for You
Mayo Clinic: Pharmacogenomics: When medicine gets personal
NSW Health – Pharmacogenetics/Pharmacogenomics
 

Last Review Date: February 13, 2019