Alison is a poor metaboliser for CYP2C19
Alison Brown (aged 58) is attending the clinic due to continued low back pain despite having had exercise therapy. You ask her about her mental health during the consult. During the past two months, she has been frequently bothered by feeling depressed and hopeless. She also has little interest or pleasure in doing things.
After discussion with Alison, you agree to refer her for CBT and that you will give her medication for the depression and the low back pain. You also recommend the TreatGxPlus pharmacogenetic service to find medication options tailored to her unique genetic and health profile.
She is using the maximum dose of acetaminophen per day (4g) for her back pain and is continuing the exercise therapy.
Alison’s pharmacogenetic report included the following results:
If entered into TreatGx depression:
You note that citalopram and escitalopram are not included due to Allison’s CYP2C19 status.
You then go to low back pain within TreatGx to find the medication options for her, remembering to add in Citalopram to the medications list.
You note the advice about gastroprotection (a PPI is advised due to increased gastrointestinal bleeding risk with the use of both a SSRI and NSAID). You prescribe Ibuprofen 200mg TID and Lansoprazole 15mg daily.
– Click here to create your Healthcare Provider account.
In the registration page, you will complete the fields below:
Username: Type a username as a provider.
Password: ≥ 8 characters long, and using 2 of the following: upper case A-Z, lower case a-z, number, special character
First Name, Last Name, Email
Healthcare Profession: Select your profession from a drop down list
Phone, Address, City, Province/Territory, Postal Code, Country, Timezone
Terms and communications
In Canada, TreatGxPlus is brought to you in partnership with LifeLabs. To order the service for patients, please visit the LifeLabs genetics website.
An invitation to view your patient’s profile is sent by email after their pharmacogenetic results are ready. This feature is available for the provider signing the requisition form. You can accept the invitation by clicking the link in the email.
If you have an account, select “Yes” and enter your username and password. If you do not have an account, select “No” and create an account. Please visit the “Creating your account” section for more information.
After you accept the invitation your patient will have been added to your case list accessible from your dashboard. You will have access to:
– Your patient’s report with his or her pharmacogenetic test results.
– Your patient’s TreatGx account online. TreatGx is a medication decision support tool that generates safe and effective options by combining genetics and health information with the best clinical evidence.
You can update/enter your patient’s health information within TreatGx, and generate personalized medication options. The patient can see changes you make to their case by entering their account.
Login to your TreatGx account to manage your patient’s medications. Click ‘TreatGx Login’ on the GenXys website and log in using your username and password.
After login, you will be directed to the TreatGx dashboard which allows you to see the patient cases you have access to.
Select the patient file you wish to enter from the left by clicking on the name:
Medication Options allows you to use the TreatGx decision support tool to create personalized medication options. If the patient has had a pharmacogenetic test the information is prefilled and cannot be changed.
Click on Current Medications to add current or past medications. The medication entry page uses a predictive-text box and medications can be entered under the relevant condition. If there is no condition in TreatGx that corresponds to the medication, it can be entered under “Other”.
Click on Current Conditions to update the conditions that appear on the patient’s home page. Simply select the conditions that are relevant to the patient and click Save. Conditions can be unselected to remove them from the patient’s list of current conditions.
View genetic report will provide you with a PDF of the pharmacogenetic report.
All the results from the genetic report are automatically uploaded into the TreatGx decision support tool and are ready to use.
To reset your password, please select ‘Forgotten your password’ on the login page. You will then be prompted to enter your username. Click ‘Reset’ and a temporary password will be sent to the email associated with the account. You can copy and paste the password to log in to the account. After loging in, please update your password.
To update your password, please select ‘My account’ in the top right corner and click ‘Change password’. You will need to enter your current password and new password.
Click the boxes to select your conditions.
After you select your patient’s conditions, scroll to the bottom of the page and select ‘Save’. For a list of all the conditions covered in TreatGxPlus, click here. TreatGx is continuously expanding and new conditions are being developed regularly.
When ‘Medication Options’ is selected from the TreatGx dashboard, the Conditions menu is seen on the left. This menu contains common medical conditions that are seen in primary care.
For a list of all the conditions and medications covered in TreatGx, click here. TreatGx is continuously expanding and new conditions are being developed regularly.
When a condition is selected (for example: Depression) the patient detail sections will appear on the right
– Sections in red indicate that more information is required to create/update medication options.
– The genetic information is preloaded if your patient orders TreatGxPlus online and their sample has been processed.
Expand each section by clicking on the plus icon and enter or update the information.
– Before selecting ‘Create/Update Personalized Rx Options’, it is important to check the information entered including Drug History and Medical History. Also ensure that the patients “Current Medications” are up to date.
In some sections you can select “None of the above”. Please do this with caution after confirming none of the above apply.
Some conditions ask for the dose of a drug or tests results. Make sure the units match your answer e.g. ml/min. Enter 0 for dose if the patient is not taking the medication.
Use the plus icon to expand each section and enter the patient’s information.
After entering or changing information, click ‘Create/Update Personalized Rx Options”.
After entering all the information, personalized medication options will be generated.
The personalized medication options include:
Patient information: includes drug history, medical history, genetics, lab values and current medications
Each medication option include:
– Generic drug name
– Individualized dose
– $ – Approximate drug cost relative to other drugs shown
– Relevant drug-drug interactions with an expandible section to read more about the interaction
Additional guidance may include non-pharmacological treatments, advice on dosage forms, how to switch drugs or other clinical advice
TreatGx is a medication decision support system created using the highest levels of evidence. Since we use the most up-to-date, highest levels of evidence, medication options displayed may differ from popular prescribing practices. The best available evidence should always be used when determining the medication options for each patient.
We include all absolute contraindications, and the major interactions with strong evidence when evaluating the safety of the medication options. Monitoring of lower level interactions, medication response, and adverse reactions is the responsibility of the healthcare professional.
What patients can I use the TreatGx software for?
We understand that all patients are different and a ”one-size fits all” approach is not always ideal. In addition to genetic variability between patients, TreatGx also takes into consideration:
• Patients with multiple conditions or medications
• Hepatic and renal impairment
• Immunocompromised patients
• Drug sensitivities and allergies
• Previous trials of medications that were ineffective or not tolerated
• Ability to access INR monitoring
• And many more
See the list of all the conditions and medications covered in TreatGx here.
What conditions are included in TreatGx ?
TreatGx starts by considering your patient’s condition, disease state or diagnosis.
See the list of all the conditions and medications covered in TreatGx here. TreatGx is continuously expanding and new conditions are being developed regularly.
Do I need the results of a genetic test to use TreatGx?
Patients cannot access TreatGx without having a pharmacogenetic test through TreatGxPlus.
Healthcare providers can add a case within TreatGx without genetic information. However, genetic testing provides important information that allows TreatGx to personalize treatment options that are safe and effective. Here are two examples:
To treat chronic gout, allopurinol is a commonly used inexpensive medication option. If a patient is positive for the genetic variant HLA B*58:01, allopurinol could cause serious, possibly fatal, skin reactions such as Stevens-Johnson syndrome. By using the pharmacogenetic test results, TreatGx will suggest febuxostat as a treatment option, instead of allopurinol, and a potentially serious adverse event will be avoided. Patients who are negative can take the cheaper drug, allopurinol.
A patient is taking fluvoxamine to control his symptoms of depression. The fluvoxamine is working well however the patient has had diarrhea and felt nauseous ever since starting the medication. He would like to know if there is a better medication for him so he sends his sample for genetic testing. Ethan carries a particular variant for a gene called CYP2D6 that makes him a ‘poor metabolizer’ for fluvoxamine when he enters TreatGx shows him that he can take a reduced dose of Fluvoxamine. With this dose adjustment, he is likely to continue taking the medication and get the benefits of the medication without the side effects of diarrhea and nausea.
I am trying to confirm that a prescribed medication is appropriate for my patient, but it is not coming up as an option. Why not?
• TreatGx is intended to be used as a decision support tool when modifying medication therapy. The software assumes the current therapy is ineffective or not tolerated and offers the next line of medication options. If you would like to use TreatGx to check the dosing for a medication or its appropriateness for a patient, remove the medication from the “current medication” list.
• You can change any of the patient attributes, except genetics, to see if the medication has been contraindicated due to one of these factors.
Related question: I am not getting the result I was expecting. Please help!
I am not getting the result I was expecting. Please help!
• Please ensure that all the patient information has been entered correctly, particularly the “Drug History”, “Medication History” and “Current Medications” sections.
• TreatGx is an evidence-based software designed to help identify safe and effective medications. While we do take into consideration popular prescribing practices within the system, we have excluded some medications or have moved them to second or third line options in accordance with the most up-to-date highest levels of evidence. The best available evidence should always be used when determining the medication options for each patient.
• “Seek Specialist Advice” may appear alongside drug options. This is often due to numerous contraindications, drug interactions, the complexity of drug regimen or severity of the disease. It may also be due to monitoring requirements for the drug, or there may be non-drug therapy that specialists can provide.
How are the algorithms developed for each condition?
• Each TreatGx algorithm takes approximately 400 hours to be developed and tested by a team of physicians, pharmacists, geneticists, epidemiologists and other healthcare professionals.
• The TreatGx team uses the highest levels of clinical evidence available. Evidence from high-quality guidelines, systematic reviews, drug interaction databases, genotype interactions, product monographs, and randomized controlled trials are combined and presented to an expert panel.
• The final medication options are optimized for each patient, determined by a set of factors including the clinical stage of the disease, the biophysical profile of the individual (age, gender, renal function etc.), concurrent medications, and the results of their pharmacogenetic test.
• This process is iterative and constantly updated with new, emerging evidence.
Is monitoring information included?
• Monitoring is the responsibility of the healthcare professional.
• Occasionally monitoring is advised within TreatGx. For example, we recommend monitoring renal function every 3-6 months for patients on metformin with declining renal function.
• All absolute contraindications and severe drug-drug interactions with strong evidence are included.
• The monitoring of the following are not included and are the responsibility of the healthcare provider:
• Additive side effects from multiple medications (ie. anticholinergic effects, QT prolongation, or electrolyte imbalances)
• Mild-moderate drug-drug interactions that may necessitate closer monitoring
• Medication response
• Adverse reactions
What is pharmacogenetic testing?
Depending on your patient’s genetic makeup, some medications may work more effectively, less effectively or cause adverse events. Our pharmacogenetic test detects genes that affect the way medications work within the body which is then combined with the best available evidence to provide medication options and dosing for your patients.
Learn more about pharmacogenetic testing in our Education Center
Can ancestry be identified with the TreatGxPlus pharmacogenetic test?
No, the TreatGxPlus service does not help identify your ancestry. Unlike other genetic tests, the TreatGxPlus service is designed only to tell you about your medication choices.
Can pharmacogenetic testing identify increased risk of certain medical conditions?
The TreatGxPlus service helps you make better medication choices by identifying only those areas of your genes that interact with medications.
The test will not inform the risk of disease, for example; cancer, vascular disease, or Alzheimer’s disease.
Why are benzodiazepines not included as treatment options in the TreatGx Anxiety Disorders algorithm?
TreatGx is an evidence-based software designed to help identify safe and effective medications for management of common conditions treated in primary care. Currently, our Anxiety Disorders algorithm includes Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD). Benzodiazepines have been shown to be effective in the treatment of GAD and SAD, but mainly for acute anxiety or agitation or while waiting for the onset of effect of other medications. However, the Canadian clinical practice guidelines for the management of anxiety (PMID 25081580) rank them as second-line therapies, and only for short-term use, due to side effects, dependence, and withdrawal issues. Choosing Wisely Canada also recognizes that while benzodiazepines may be helpful for short-term relief of anxiety, they should be tapered and discontinued as soon as possible to prevent long-term problems including cognitive and psychomotor impairment as well as abuse and dependence. In elderly patients, benzodiazepines are also responsible for falls and fractures which is why they have been included in both the Beers’ and STOPP criteria lists of potentially inappropriate medications in the elderly (PMID 18829684). The NICE clinical practice guidelines for SAD (CG159) recommend not routinely offering benzodiazepines to treat SAD in adults, and the NICE clinical practice guidelines for GAD (CG113) recommend not offering benzodiazepines in primary or secondary care except as a short-term measure during crises. Benzodiazepines may also complicate some common anxiety comorbidities, such as depression. Based on these factors, many discussions within our team and with external consultants, and a more thorough review of the literature, the decision was made to not include benzodiazepines in our current GAD and SAD treatment algorithms. Further, there are currently no pharmacogenetic dosing guidelines (or high-level clinical evidence) for any of the benzodiazepines that have evidence for use in anxiety.
In the future, these medications may be included as treatment options for acute anxiety or agitation algorithms within TreatGx.
Does the TreatGxPlus pharmacogenetic test predict which patients may experience adverse reactions with ciprofloxacin?
Ciprofloxacin is included in the TreatGx software as a medication option in UTI. In terms of toxicity, rare severe adverse effects associated with ciprofloxacin (and other fluoroquinolones) may include peripheral neuropathy or tendinopathy. However, there is currently no compelling evidence regarding a genetic predisposition to these effects. Literature searches reveal two case reports of possible ciprofloxacin-induced hemolytic anemia in G6PD-deficient patients (PMID: 11273551, PMID: 20127091), but there is a general lack of evidence for this association. In UTI, empiric use of ciprofloxacin is reserved for second-line therapy in uncomplicated UTI, for pyelonephritis, and for complicated UTIs if there are no culture & sensitivity results available. In these cases, ciprofloxacin may be the best option to resolve the infection and prevent further complications, despite a risk (<1%) of these adverse effects. In light of this lack of evidence and the important role of ciprofloxacin in the treatment of certain infections, we currently do not test for any genetic variants associated with ciprofloxacin toxicity on our panel nor include them in TreatGxPlus.
DS Double strength
EC Enteric coated
DPI Dry powder inhaler
pMDI Powdered metered dose inhaler
SC Subcutaneous injection
IV Intravenous injection
IM Intramuscular injection
IBW Ideal body weight
To learn more about pharmacogenetics, levels of evidence, pharmacokinetics, pharmacodynamics, and more please visit our Education Center