Dynamic and accessible pharmacogenomic results: a response to pharmacogenomic testing for antidepressant treatment selection

We thank Drs. Frye and Nemeroff for their perspective on the promising role of pharmacogenetics (PGx) in the selection of antidepressant treatment [1]. In their article, Frye and Nemeroff discuss several challenges to the wide-scale application of PGx for the treatment of depression. We agree that there are several challenges to address, particularly regarding electronic health record (EHR) integration, in order for PGx to become a widely utilized resource for antidepressant selection and dosing.

EHR functionality is required for PGx implementation to succeed, including readily accessible, discrete results and integrated clinical decision support (CDS). PGx laboratory results are shared in several ways with patients and providers: as paper reports which are subsequently scanned into the EHR and/or manually entered into a patient’s chart; as electronic files uploaded into the media section of the EHR; in patient or provider-facing websites independent of the EHR; or as laboratory results directly transmitted via HL7 messaging. Returning results and providing CDS in static formats, such as electronic files, do not allow for the interpretation or prescribing recommendations to change as PGx knowledge evolves. For example, the 2023 Clinical Pharmacogenetics Implementation Consortium (CPIC) serotonin reuptake inhibitor guidelines provide actionable recommendations for sertraline based on CYP2B6 metabolizer status, whereas previous CPIC serotonin reuptake inhibitor guidelines did not [2, 3]. CDS returned in electronic file formats prior to 2023 would not contain CYP2B6/sertraline recommendations, therefore not reflecting current consensus. To ensure accurate and high-quality patient care, CDS must be revised periodically and dynamically changed as evidence and treatment recommendations are updated.

Furthermore, because PGx results are useful among many disease states, it is crucial that discrete results and CDS are accessible to all clinicians, not just the ordering clinician. For example, patients with depression frequently have comorbid medical diagnoses, such as pain and cardiovascular disease [4]. Medications used to treat these disease states have important drug-gene interactions with genes assayed for antidepressant selection (for example, CYP2C19/clopidogrel, CYP2D6/codeine), making it imperative that all providers, regardless of specialty, can view and utilize PGx results [5].

While building EHR functionality to support PGx can be a large time investment, current literature shows promise that PGx-guided antidepressant treatment may improve symptom remission [6]. As PGx becomes more widely utilized and continues to evolve, so should best practices for EHR functionality. We believe that the incorporation of discrete results and dynamic CDS into the EHR will provide up-to-date treatment guidance and will allow PGx to be robustly studied and utilized across multiple disease states, including major depressive disorder, positively impacting the holistic care of our patients.

Author contributions

Christina Sun drafted the initial correspondence manuscript. Lucas Berenbrok and James Stevenson provided guidance regarding discussion points and reviewed and edited the manuscript.

Competing interests

The authors declare no competing interests.