Pediatric considerations for pharmacogenetic selective serotonin reuptake inhibitors clinical decision support

Abstract

Pharmacogenetic testing for psychiatry is growing at a rapid pace, with multiple sites utilizing results to help clinical decision‐making. Genotype‐guided dosing and drug selection have been implemented at several sites, including Vanderbilt University Medical Center, where clinical decision support (CDS) based on pharmacogenetic results went live for selective serotonin reuptake inhibitors in 2020 for both adult and pediatric patients. Effective and appropriate implementation of CYP2D6‐ and CYP2C19‐guided CDS for the pediatric population requires consideration of the evidence for the pharmacogenetic associations, medication indications, and appropriate alternative therapies to be used when a pharmacogenetic contraindication is identified. In this article, we review these pediatric pharmacogenetic considerations for selective serotonin reuptake inhibitor CDS. We include a case study, the current literature supporting clinical recommendations, considerations when designing pediatric CDS, future implications, and examples of sertraline, (es)citalopram, paroxetine, and fluvoxamine alerts.

A Narrative Review on Pharmacogenomics in Psychiatry

“…Furthermore, it is essential to highlight that the PGx data presented in this review pertain to adult populations and cannot be directly translated to children. Notably, the scientific literature also provides evidence of the clear utility of using PGx testing to guide dosing in pediatric patients 66 . The CPIC database includes specific guidelines dedicated to pediatric psychiatry, distinct from those for adults (eg, atomoxetine) 66 .…”

“…Notably, the scientific literature also provides evidence of the clear utility of using PGx testing to guide dosing in pediatric patients 66 . The CPIC database includes specific guidelines dedicated to pediatric psychiatry, distinct from those for adults (eg, atomoxetine) 66 . Indeed, at Vanderbilt University Medical Center, CYP2D6 and CYP2C19 PGx testing has been incorporated as clinical decision support for the treatment of pediatric patients with SSRI 66 .…”

“…The CPIC database includes specific guidelines dedicated to pediatric psychiatry, distinct from those for adults (eg, atomoxetine) 66 . Indeed, at Vanderbilt University Medical Center, CYP2D6 and CYP2C19 PGx testing has been incorporated as clinical decision support for the treatment of pediatric patients with SSRI 66 . However, an ongoing debate surrounds the strength of scientific evidence regarding PGx-guided treatment with psychotropic drugs in children, primarily because of the lack of well-designed prospective studies in this population 66 …”

“…66 Indeed, at Vanderbilt University Medical Center, CYP2D6 and CYP2C19 PGx testing has been incorporated as clinical decision support for the treatment of pediatric patients with SSRI. 66 However, an ongoing debate surrounds the strength of scientific evidence regarding PGx-guided treatment with psychotropic drugs in children, primarily because of the lack of well-designed prospective studies in this population. 66 At last, although not within the primary scope of this review, it is essential to acknowledge the extensive research conducted to identify the key factors contributing to the cautious stance of clinical psychiatry regarding the integration of routine PGx testing (check all Refs.…”

“…66 However, an ongoing debate surrounds the strength of scientific evidence regarding PGx-guided treatment with psychotropic drugs in children, primarily because of the lack of well-designed prospective studies in this population. 66 At last, although not within the primary scope of this review, it is essential to acknowledge the extensive research conducted to identify the key factors contributing to the cautious stance of clinical psychiatry regarding the integration of routine PGx testing (check all Refs. 67, 68, and 69, just to cite a few) with the aim of implementing strategies to overcome them.…”