How do I order genetic testing for psychotropics?

[psych]

Hi, please excuse me if this is straightforward. Patients at a new clinic I work at are asking for this... I come from jail, prison, low income clinics so this is not part of the typical labs I order. Sometimes patients would bring in a report which I would review, and occasionally found it helpful but I've never ordered it myself. I asked the clinic and they told me they have nothing to do with it but a lot other providers order this testing quite often. Any guidance/tips?

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[Stagg737]

Yes, unless a patient has been through a ton of meds that were ineffective or intolerable already, don't do it.

 

[Ironspy]

just go to the companies website and make an account. You can order a home test kit to get sent to the patient’s home. I agree that I only do this if multiple meds are not tolerated

 

[psych]

And who pays for this?

 

[calvnandhobbs68]

And who pays for this?

Genesight is the most common test for this (surprised you haven't run into their reps already lol). They basically send you kits you use to swab the patient's mouth and fedex back.

Insurance variably approves this, medicare/medicaid is actually a bit better at paying than private insurers. Genesight has a thing where they'll contact the patient if their OOP cost will be over $330.

 

[deleted1100659]

I think often time the patients ask for it because they are under the impression its a magic way of knowning which medications will be perfect/work for them. I usually give education about it and explain that isnt the case.

 

[birchswing]

<Not a doctor or student>

I never had to do this because I had a psychiatrist who was so fanatical about genetic testing she had me genetically tested three times through three companies (was also the type into a lot of supplements) so I have more genetic-drug interaction info than I need, BUT if the person wants to do it on the cheap and insurance won't cover it (mine did for some reason three times), you can use Ancestry or 23 and Me, and then download the raw data and upload it to Promethease.

Upside: It's a lot cheaper
Downside: It's not official and you can find out a lot of stuff you don't want (BRCA etc)

 

[allantois]

You can also order it to be shipped to patient's house for self-swab. Results come back within a week. Then they will bill insurance and if it's not covered they will bill the patient. The patient can call their insurance to see if they will pay. United and BCBS seem to pay. Patients with autism almost always come back with all sorts of genetic interactions. It also tests for HLA genes as well as MTHFR

 

[allantois]

<Not a doctor or student>

I never had to do this because I had a psychiatrist who was so fanatical about genetic testing she had me genetically tested three times through three companies (was also the type into a lot of supplements) so I have more genetic-drug interaction info than I need, BUT if the person wants to do it on the cheap and insurance won't cover it (mine did for some reason three times), you can use Ancestry or 23 and Me, and then download the raw data and upload it to Promethease.

Upside: It's a lot cheaper
Downside: It's not official and you can find out a lot of stuff you don't want (BRCA etc)

I have looked it up and it is not the same. I have seen some companies online offer limited pharmacogenomic testing of 1 or 2 genes. I think genetic testing will become more widespread in the future (perhaps even done for everyone), but I agree that utility at this time is limited, however, it may be useful even in those who have never been on medications if this is the route they really want to pursue (would probably add to the placebo effect of whatever medication we would end up choosing lol)

 

[birchswing]

I have looked it up and it is not the same. I have seen some companies online offer limited pharmacogenomic testing of 1 or 2 genes. I think genetic testing will become more widespread in the future (perhaps even done for everyone), but I agree that utility at this time is limited, however, it may be useful even in those who have never been on medications if this is the route they really want to pursue (would probably add to the placebo effect of whatever medication we would end up choosing lol)

I was under the impression that Promethease gave you more and not less information than the official companies, but I haven't used it.

Were you looking at 23andMe's official pharmacogenetic offering? Until you wrote, I didn't even know they were offering that as an official result. I just looked it up now. The Promethease service I mentioned is different. I haven't use it. But essentially you download the "raw data" (I honestly don't know what that is—your entire genome?) from a service like Ancestry or 23andMe, which includes information they didn't provide results on. Promethease is then a low-cost service you can upload the data to that will interpret it for you.

I've personally avoided all these things. This isn't a strong opinion. But it's like a very lukewarm opinion I have: These services started out with people finding about about their ethnic background through their genes. People did it for fun, to feel good. It was exciting and novel that I'm this or that ethnicity. You might say they felt "good" about finding out they were a certain ethnicity. From Greek we have the word "eu" for good. Eu plus genes. Eugenics. Not saying people have bad intentions. Just always something I had in the back of my mind about it. And now people do it to find out what their dog is. It's harmless, I guess. Just more a personal aversion I have to it.

 

[allantois]

I’m comparing it to pharmocogenomic testing such as Genesight that has to be ordered professionally

 

[birchswing]

Gotcha.

Out of all the tests my provider did, which included Genesight, Genelex was my favorite by far because of the drug-drug and drug-gene interaction checker it came with, called YouScript.

Again, this was nothing I solicited. She was just really into this.

YouScript was free to patients, but they turned into a service that is for doctors with panels of patients, but I actually still pay for it just because it's by far the best drug interaction checker I've used, even if it didn't show gene interactions, as well.

As a recent example, with Paxlovid, I was able to look up my interactions, and that's a pretty complex and new thing have interactions listed for. But for each of my meds, it forecasts the impact and gives references for every single claim it makes that you can look up on PubMed.

I've also really liked that they take my feedback. I've e-mailed them several times with mistakes I've found or interactions they haven't included (particularly psychiatric drugs with antibiotics), and they have in some instances updated the database with my suggestions.

If I were a doctor (or even a pharmacist—yes I know they're doctors, too) I would pay for YouScript. For me, it's extravagant because I'm the only one using it, and the cost covers an entire panel. My doctor just sent in Paxlovid with no counseling and no counseling from the pharmacist. His nurse walked out and hasn't been replaced in a year, so the whole office is skeletal and running on fumes. I had to rely on that resource myself. It's helpful for when things like that come up. It shows all the metabolic pathways for each drug, and it lets you pick alternates by drug class or indication. Overkill for me. But it's an indulgence, I guess you could say. Although, there really are some interactions that for me are meaningful (just knowing that I have 400% increased exposure to ibuprofen as a small example). And without going into detail, which drug I needed to drastically reduce on Paxlovid. I tried getting my doctor to go in on it half-way with me to give him access to it, but he didn't bite. I have no association with it, other than being an over-paying member. But I think it's good. When they got rid of the consumer option, I talked to the people who work there quite a bit, and they said they really wanted to target doctors instead. I kept telling them that people going out on their own (smart devices, self ordered blood testing, etc) was more the wave of the future. My doctor's office is like a DMV. They can't even call scripts out (well they did with Paxlovid but haven't called in the ICD codes for my glucose strips since the nurse quit so I self-pay for those now). Doctors don't have time for this, but patients do. It's saved me from mistakes with my dentist too, who gave me Tramadol and told me it wasn't an opioid. Not only did I find out it is an opioid, I found out it had serotonergic interactions among others I won't get into. I digress.

I'm not entirely sure how Genelex and Youscript relate to each other. All I know is that after the Genelex testing, I had free access to YouScript and that's where all the Genelex data is still stored and where I can check drug-gene interactions. I'm not sure if they are the same company or if they just work together. I can't say enough good things about YouScript. I'd check out the free trial. I know I sound like a spokesperson. And I've told my doctor to try out the free trial, as well, but for some reason--well I guess there is a reason, everyone is too busy.

 

[Sikrouf]

Failing several medications trials have me look into diagnosis error, psychodynamics or psychopathology, drug levels for observance and pharmacokinetic failures and environmental insults be it as past trauma or current issues such as drugs of missuse, disrespect for circadian rythme, etc

I dont see any useful information coming from a gen test with several treatment failure
Regardless of the test as far as pharmacology goes i ll be trying drugs with another mechanism of action or a different metalobic pathway

 

[Merovinge]

Please look at actual guidelines (international ones are the best) for how CYP genomic information actually impacts real world prescribing. What genesite lists is NOT representative of reality. The stupid stoplight green,yellow,red made the company a gagillion dollars but obfuscates med choices and there is some work that shows it can cause harm to follow these recommendations. We have real clinical studies that are not industry sponsored to inform this. You also need to understand what hypermetabolism looks like (i.e. earlier side-effects, earlier main effects, wearing off early, not just failure to effect). Certainly there are some real changes that will impact dosing like cyp2C19 if you are using Lexapro/Celexa/Zoloft (later was not clear to me until this past years AACAP).

 

[Penguin10]

Please look at actual guidelines (international ones are the best) for how CYP genomic information actually impacts real world prescribing. What genesite lists is NOT representative of reality. The stupid stoplight green,yellow,red made the company a gagillion dollars but obfuscates med choices and there is some work that shows it can cause harm to follow these recommendations. We have real clinical studies that are not industry sponsored to inform this. You also need to understand what hypermetabolism looks like (i.e. earlier side-effects, earlier main effects, wearing off early, not just failure to effect). Certainly there are some real changes that will impact dosing like cyp2C19 if you are using Lexapro/Celexa/Zoloft (later was not clear to me until this past years AACAP).

Did you come away from AACAP with any practical tips about clinical application? Would you check just cyp2C19 if relevant clinical situation (so not one of the panels) or just switch to an agent not involving cyp2c19?

 

[calvnandhobbs68]

Please look at actual guidelines (international ones are the best) for how CYP genomic information actually impacts real world prescribing. What genesite lists is NOT representative of reality. The stupid stoplight green,yellow,red made the company a gagillion dollars but obfuscates med choices and there is some work that shows it can cause harm to follow these recommendations. We have real clinical studies that are not industry sponsored to inform this. You also need to understand what hypermetabolism looks like (i.e. earlier side-effects, earlier main effects, wearing off early, not just failure to effect). Certainly there are some real changes that will impact dosing like cyp2C19 if you are using Lexapro/Celexa/Zoloft (later was not clear to me until this past years AACAP).

Right I just had to explain this this week for someone who had genesight testing before they came to me. Just because Prozac is in the “yellow” or “red” group doesn’t mean I’m not going to use it for a kid with MDD. Once I explained what the heck the test actually meant the mom was also much less distressed that Zoloft was in the “green” group but hadn’t helped much.

 

[comp1]

Don't do this. Even if somehow insurance pays for it, you're contributing to the cost of increased healthcare without demonstrable benefit.

 

[Merovinge]

Did you come away from AACAP with any practical tips about clinical application? Would you check just cyp2C19 if relevant clinical situation (so not one of the panels) or just switch to an agent not involving cyp2c19?

Depends on the pt's response, if I get a great response but they seem to feel worse every evening (with daily dosing, I have literally 1 patient like this), then I would strongly consider the testing as it appears to be hypermetabolism (presuming it is Lexapro/Zoloft). If they take a long time to respond (but do respond such that you want to keep the medication going) and have higher SE burden later into starting then certainly it can be reasonable to test for hypometabolism. P-glycoprotein transporter variation is also worthwhile to test for, but in the absence of testing you can just use medications that do not move through it. This practically means that if you start w/ Lexapro or Zoloft, the second med should be Prozac and not the contra of Lexapro/Zoloft (as Prozac does not get pumped out through the Pglycoprotein system). I believe Wellbutrin and Effexor also do not use this system (please correct me if I am wrong and I will edit, I can never remember which of the 2 SNRIs it is).

In practice, I do not know how to order a specific one without getting a panel, but I know some healthcare systems allow this, and if there is cost savings associated, I would recommend it.

I do believe the initial 2D6 metabolism research is showing this does not clinically impact medication decisions, but will note that I am not as up-to-date on this all as I should be given other clinical and life demands in the past year.

 

[Penguin10]

Depends on the pt's response, if I get a great response but they seem to feel worse every evening (with daily dosing, I have literally 1 patient like this), then I would strongly consider the testing as it appears to be hypermetabolism (presuming it is Lexapro/Zoloft). If they take a long time to respond (but do respond such that you want to keep the medication going) and have higher SE burden later into starting then certainly it can be reasonable to test for hypometabolism. P-glycoprotein transporter variation is also worthwhile to test for, but in the absence of testing you can just use medications that do not move through it. This practically means that if you start w/ Lexapro or Zoloft, the second med should be Prozac and not the contra of Lexapro/Zoloft (as Prozac does not get pumped out through the Pglycoprotein system). I believe Wellbutrin and Effexor also do not use this system (please correct me if I am wrong and I will edit, I can never remember which of the 2 SNRIs it is).

In practice, I do not know how to order a specific one without getting a panel, but I know some healthcare systems allow this, and if there is cost savings associated, I would recommend it.

I do believe the initial 2D6 metabolism research is showing this does not clinically impact medication decisions, but will note that I am not as up-to-date on this all as I should be given other clinical and life demands in the past year.

Very helpful, thanks.