CYP450 testing

[randomdoc1]

What is everyone's opinion about this? My understanding is that there is some evidence that assays like genesight's can provide some insight and possible benefit to selecting an antidepressant that works out better for the patient. However, in my experience, it really hasn't been that helpful. In many cases, patients who complain of a lot of side effects were found to be on medications which there is no evidence of a gene drug interaction, some could have been their anxiety or how they perceived the treatment. I had a couple instances where there was reported to be a gene drug interaction with a medication the patient had been doing extremely well on and when a previous provider dc'ed the medication based on the genesight results they decompensated. There's obviously a lot more to the pharmacology than liver metabolism. Anyone have any insights or experiences to share? Thanks!

---

Members don't see this ad.

 

[Nasrudin]

I’ve had this question brewing for awhile myself. I did a literature search a year ago and couldn’t find evidence for a practice altering use of the testing unless it uncovered a reason to use high doses of a medication. Such that I couldn’t justify an expense for the benefit except perhaps at levels of income at which casual luxuries are normal for the person.

And as far as I know insurance companies aren’t paying for it.

 

[nitemagi]

Insurance pays for it much of the time if it's justified (prior failed trials, abnormal reactions to meds, etc). Most of these companies have an agreement that if insurance doesn't pay they charge the patient around $300 out of pocket, which is usually doable.

I can't say it's been a massive breakthrough, but it allows for a little more targeted trial-and-error, and it definitely gives patients a bit more confidence in the process (maybe false confidence but it keeps them in the game).

 

[birchswing]

I had it done. Knowing the results I know now, I would have paid for it myself regardless of any impact on psychiatric prescribing. Helped when I had a surgery due to altered warfarin response.

I also really like YouScript's drug interaction checker. You can check drug-drug and gene-drug impacts, and each impact is rated based on strength of evidence with a link to citations for each assertion.

 

[Trismegistus4]

What is everyone's opinion about this? My understanding is that there is some evidence that assays like genesight's can provide some insight and possible benefit to selecting an antidepressant that works out better for the patient. However, in my experience, it really hasn't been that helpful. In many cases, patients who complain of a lot of side effects were found to be on medications which there is no evidence of a gene drug interaction, some could have been their anxiety or how they perceived the treatment. I had a couple instances where there was reported to be a gene drug interaction with a medication the patient had been doing extremely well on and when a previous provider dc'ed the medication based on the genesight results they decompensated. There's obviously a lot more to the pharmacology than liver metabolism. Anyone have any insights or experiences to share? Thanks!

My experience has been exactly like yours. I've tended to order it on people who claim total inefficacy of, or severe and/or unusual side effects to, every medicine they've ever tried, in the hopes that the results will illuminate a reason for this... but they never do. I've had people who claim nothing works and they couldn't tolerate anything come back with no gene-drug interaction with any med, and I've had people who are doing fine on their current meds (but wanted the test for some other reason) come back with significant gene-drug interactions with those same meds.

 

[OldPsychDoc]

Insurance pays for it much of the time if it's justified (prior failed trials, abnormal reactions to meds, etc). Most of these companies have an agreement that if insurance doesn't pay they charge the patient around $300 out of pocket, which is usually doable.

I can't say it's been a massive breakthrough, but it allows for a little more targeted trial-and-error, and it definitely gives patients a bit more confidence in the process (maybe false confidence but it keeps them in the game).

Except that it gets WAY oversold by some providers--such that patients show up with the printout in their hands demanding that they get "the one the test says is the right one for me!"

 

[OldPsychDoc]

...A little information can be more dangerous than none.

A little Learning is a dang'rous Thing;
Drink deep, or taste not the Pierian Spring:
There shallow Draughts intoxicate the Brain,
And drinking largely sobers us again.
--Alexander Pope, 1709

 

[DisorderedDoc417]

Except that it gets WAY oversold by some providers--such that patients show up with the printout in their hands demanding that they get "the one the test says is the right one for me!"

THIS. And it is sold as “x drug is listed as a good drug for me” to patients. Always requires 15 minute conversation with the patient explaining that how ones body metabolizes a certain drug doesn’t mean the drug is going to help or not help. I think it’s just an addition to the many “promising future pathways” we seem to be in no shortage of in psychiatry.

 

[randomdoc1]

I’ve definitely seen the testing generate some nocebo responses. One pt said they were having terrible SE and pointed out the drug I prescribed was in “the yellow”. Then I pointed out the footnote said it was because he may be a fast metabolizer and need HIGHER doses. For other pts it gives them peace of mind and helps with drug compliance. Despite the discussion that this test is far from the be all end all.

 

[splik]

I hopped onto the bandwagon some years ago but don't use it anymore. I didn't like how aggressive the genesight reps were. Patients really like it. It is ultimately snake oil. Insurance does cover it including medicare. I would use it for patients with treatment-resistant mood disorders or who were poorly tolerating multiple drugs. I think it can potentially give helpful info if someone is an ultrarapid metabolizer or if they are a poor metabolizer. Of course this does not take into account pharmacodynamic effects (there are obviously other reasons why some people are more sensitive to drugs than others vs nothing works). If someone has significant personality pathology I would be inclined to skip the testing... There are some psychiatrists who are doing this testing on EVERY patient, which is not a good idea. In some areas, medicaid pays for it and literally every medicaid pt is getting it. what a waste of money. I think it can be a useful data point in carefully select patients, as well as used to anchor the therapeutic relationship and make it seems like there is some method in the madness of psychiatry.

As always, we should treat the patient, not the test result.

The testing now includes voodoo like MTHFR etc, it's not just cytochrome SNPs that they look at.

 

[Nasrudin]

Seems like schnazzy private practice fluff to make you look hip. Something to sell to rich dummies. The fact that medicaid is paying for it is... just... welp. I'm not surprised. There's no effort or expense or comfort that is too much for psychiatry's own re-tarded babies.

 

[birchswing]

One thing that might make you all gag a bit is that I've actually had three genetic tests, all of which are duplicates for the most part, all ordered by the same doctor. The first when I first met my psychiatrist and said she did it on all patients (don't remember name of it). She seemed to think it would change the future of psychiatry, but it didn't for me (no med changes). Second many years later (that was YouScript for which I have web access so I like it). Then third was GeneSight because psychiatrist said it now covered more categories which I needed. Never asked for any of them. Results were never discussed except for the second (YouScript) which showed I had MTHFR variation that based on my own research was totally normal, but psychiatrist insisted on me taking Deplin in spite of me not having depression (and as I said in spite of the results showing that even with my variation I needed no intervention: 677C>T CT / 1298A>C AA—I can't remember what research I did or what those genes now mean, but I spent a lot of time researching it and eventually concluded that while I have a variation it's the same as being "normal"--psychiatrist strongly disagreed but I had to let it go). She wanted me to take Deplin before the genetic test, and then after the test said I really needed to take it (at the time it was $100 a month for a supplement you could buy over the counter). Haven't heard any mention of Deplin in years, though. She tends to gravitate toward a new thing like that at each appointment.

Having said that, YouScript was the only helpful one because I got my own ongoing online access to results (free for students) and drug interaction checker. I mainly just really like their drug interaction checker. It's found stuff drugs.com doesn't and some doctors/pharmacists don't seem to be aware of and is quite nuanced.

Another gag: *Someone* paid for all of this. I'm not sure who. I do have Medicaid as secondary insurance, so maybe it was them. I remember on one of them I signed something saying that I understood that the company would attempt to charge my insurance multiple times but if they failed I would not be responsible for payment. I never paid anything personally for any of them.

It was definitely an example of ... well, whatever the opposite of utilitarianism, prudence, ethics, etc is.

Knowing what the YouScript product is now though, I would have paid for it out of pocket as a commercial product (assuming price was 200 -300 or so).

 

[nitemagi]

I think overall until we're at the stage of measuring gene expression and not just genes we're still quite in the dark. I have had a few patients who refused to try medications and this was the factor that changed their mind, as if the testing someone legitimized psychopharm.

 

[DisorderedDoc417]

I think overall until we're at the stage of measuring gene expression and not just genes we're still quite in the dark. I have had a few patients who refused to try medications and this was the factor that changed their mind, as if the testing someone legitimized psychopharm.

Perhaps this is my ignorant resident mind at play here, but I become cynical when we start talking about things like this because the parallel I draw to general medicine would be like getting a test to measure the gene expression of someone with "fever" as a complaint and using genetic testing to determine which antibiotic would be appropriate.

 

[nitemagi]

Perhaps this is my ignorant resident mind at play here, but I become cynical when we start talking about things like this because the parallel I draw to general medicine would be like getting a test to measure the gene expression of someone with "fever" as a complaint and using genetic testing to determine which antibiotic would be appropriate.

Nah, you're right to be skeptical.

We all have to acknowledge that our current approach to psychopharm is quite imprecise, and if we can get past our current blind algorithms that's a good thing to aim for.

It's emerging technology, is all I'm saying. Are you an early adopter, or want to wait for a couple generations in to work out all the bugs?

 

[DisorderedDoc417]

Nah, you're right to be skeptical.

We all have to acknowledge that our current approach to psychopharm is quite imprecise, and if we can get past our current blind algorithms that's a good thing to aim for.

It's emerging technology, is all I'm saying. Are you an early adopter, or want to wait for a couple generations in to work out all the bugs?

My facility has robust genetics dept so we are definitely on the early-adoption side of things. Thus I restrain myself with healthy skepticism as you note above

 

[Liquid8]

Not a fan. If someone is a fast metaboliser, one can discern this based on the presence of withdrawal symptoms or medications appearing to wear off earlier than expected after initial administration. I don't need to rely on a blood test to work this out, and the hypothesis can be confirmed by getting patients to divide their dose. Slow metabolisers will generally require a lower dose of medication to be effective and I would assume most of us would adhere to some form of "start low/go slow" principle when initiating new medications.

Here the tests are also a few hundred dollars a pop, which is money I'd rather the patients pay me instead

 

[FlowRate]

Apparently there are a lot of child-psych providers (I suspect many are NP's) who are pushing this such that a ton of parents were bringing these in while I was on inpatient child earlier this year. I have found it to be completely useless. Especially when a lot of those kids had only had one or two med trials in the first place.

ultrarapid metabolizer or if they are a poor metabolizer.

The testing now includes voodoo like MTHFR etc, it's not just cytochrome SNPs that they look at.

Do you have a sense of the difference between being rapid/extensive metabolizer (most people/average) and ultra-rapid? Is it a meaningful difference beyond the dose escalations you'd normally use?

On the other end, I think the people who are poor metabolizers can tell you because they're "very sensitive" to medications which--whether personality or legit--still ends with you starting extra-low and increasing slowly, as usual.