Personalized Medicine

When a person goes to their doctor for treatment, they want to be heard, treated with respect, vent in a safe place, have viable options for treatment, and in the end achieve recovery from their symptoms. Personalized medicine takes patient care to the next level, tailoring those treatment options specific to each individual. Pharmacogenomics is the study of variations of in our genes that affects drug response, and is one of the most exciting areas of personalized medicine today. Although all FDA approved medications have proven they work for the disease they are indicated, real-life experiences tell a different story. Often, a person will have tried several medications before getting referred to a psychiatrist for a treatment-resistant illness. By that time, there’s often demoralization and feelings of hopelessness that they will never find a medication that will work for them. One of the big reasons why people respond differently to medications is our genetics.

Clinical experience says that a medication that worked well for your family member may work well for you. Why is that? Because you share genetics with your family member! However, we inherit half our genes from each of our parents, so your genetic mix for a particular enzyme or protein may not be exactly like your parents. Our Cytochrome P450 enzymes (abbreviated CYP) break down most medications, so that they can be processed and eventually eliminated from our bodies. Different medications are broken down by different enzymes. For example, even though Celexa didn’t work for you, that doesn’t mean that Zoloft or Prozac or Effexor won’t, because Celexa is metabolized by a different enzyme than the others. You’re probably someone with genetics that make an ultrarapid enzyme that breaks down and inactivates the Celexa faster than expected, basically making it seem like you’re not even taking the medication. The other antidepressants are processed by other CYP enzymes, so you’ll probably respond as expected to a different medication, which gives it a better chance at working to decrease your symptoms. Conversely, if you’ve had side effects from a particular medicine, then it’s likely that your CYP enzyme that metabolizes that particular medication is working poorly, leading to higher than expected levels of the medication in your system.

The office can also test for a variety of other genetic differences, including genes involved with response to other medications such as stimulants, antipsychotics, and those used in the treatment of addiction. Other common tests include MTHFR (last step in the folate-processing pathway) and COMT (the enzyme that breaks down dopamine), both of which can affect treatment options. There aren’t any genetic tests that are currently recommended that reliably test for disease state (such as whether you have bipolar disorder or not).

Using pharmacogenetic testing is an objective tool that your doctor has to make better informed decisions about your medication choices to personalize your treatment specifically to you. The office uses several different companies for this testing (currently Millennium Health and GeneSight, both of which are HIPAA compliant), and it can be done quickly and easily in-office with a cheek swab. The office then sends your sample to the external company, who processes the sample, returns results to the doctor within 5 business days, and bills your insurance company (just like any other lab work you would normally have completed). Dr. Victoria Kelly is a faculty educator for Millennium Health, and associate professor at UTMC’s Psychiatry department, and lectures on topics including pharmacogenomics in mental health. Neither Dr. Kelly nor Dr. Arar have any financial interest in these companies, or benefit financially in any way from ordering these tests. Billing is handled by the specialty laboratory, not the doctor’s office, just like if you went to a lab to get regular cholesterol blood work done. These external companies have contracted with many insurance companies for payment of services, but you may be responsible for a copay or unpaid portions. These external companies do have hardship programs available to reduce the fee for their tests for those patients that qualify. Or if you prefer, there are companies that offer direct-to-consumer genetic testing, such as 23andme. For those tests, you sign up and purchase them online, then they mail you the kit, you provide a saliva sample and send it back to the company. Those tests provide raw genetic data and it takes about 2 months to get that information. It then requires a third-party program to analyze the raw genetic information, and then finally a physician to help interpret it.

In summary, according the FDA, personalized medicine seeks to reduce the burden of disease by targeting prevention and treatment more effectively. With the help of personalized medicine, the health care management paradigm will focus on prevention, moving from illness to wellness, and from treating disease to maintaining health. By improving our ability to predict and account for individual differences in disease diagnosis, experience, and therapy response, personalized medicine offers hope for diminishing the duration and severity of illness, shortening product development timelines, and improving success rates. At the same time, it may reduce healthcare costs by improving our ability to quickly and reliably select effective therapy for a given patient while minimizing costs associated with ineffective treatment and avoidable adverse events. If you think personalized medicine is right for you, contact the office for more information.