Implementation of clopidogrel pharmacogenetic clinical decision support for a preemptive return of results program

Christina L Aquilante; Katy E Trinkley; Yee Ming Lee; Kristy R Crooks; Emily C Hearst; Simeon M Heckman; Kaitlyn W Hess; Elizabeth L Kudron; James L Martin; Carolyn T Swartz; David P Kao

doi:10.1093/ajhp/zxae008

Implementation of clopidogrel pharmacogenetic clinical decision support for a preemptive return of results program

Am J Health Syst Pharm. 2024 Jan 22:zxae008. doi: 10.1093/ajhp/zxae008. Online ahead of print.

Authors

Affiliations

¹ Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
² Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
³ Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
⁴ Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and Department of Pathology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
⁵ Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and UCHealth, Aurora, CO, USA.
⁶ UCHealth, Aurora, CO, USA.
⁷ Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and Department of Biomedical Informatics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
⁸ Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, and Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.

PMID: 38253063
DOI: 10.1093/ajhp/zxae008

Abstract

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Purpose: To describe our experiences implementing and iterating CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support (CDS) tools over time in the setting of a large health system-wide, preemptive pharmacogenomics program.

Summary: Clopidogrel-treated patients who are genetically predicted cytochrome P450 isozyme 2C19 intermediate or poor metabolizers have an increased risk of atherothrombotic events, some of which can be life-threatening. The Clinical Pharmacogenetics Implementation Consortium provides guidance for the use of clopidogrel based on CYP2C19 genotype in patients with cardiovascular and cerebrovascular diseases. Our multidisciplinary team implemented an automated, interruptive alert that fires when clopidogrel is ordered or refilled for biobank participants with structured CYP2C19 intermediate or poor metabolizer genomic indicators in the electronic health record. The implementation began with a narrow cardiovascular indication and setting and was then scaled in 4 primary dimensions: (1) clinical indication; (2) availability across health-system locations; (3) care venue (e.g., inpatient vs outpatient); and (4) provider groups (eg, cardiology and neurology). We iterated our approach over time based on evolving clinical evidence and proactive strategies to optimize CDS maintenance and sustainability. A key facilitator of expansion was socialization of the broader pharmacogenomics initiative among our academic medical center community, accompanied by clinician acceptance of pharmacogenetic alerts in practice.

Conclusion: A multidisciplinary collaboration is recommended to facilitate the use of CYP2C19 genotype-guided antiplatelet therapy in patients with cardiovascular and cerebrovascular diseases. Evolving clopidogrel pharmacogenetic evidence necessitates thoughtful iteration of implementation efforts and strategies to optimize long-term maintenance and sustainability.

Keywords: CYP2C19; clinical decision support; clopidogrel; cytochrome P450 isozyme 2C19; implementation; pharmacogenetics; pharmacogenomics.