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Can precision medicine and protocols coexist?

March 31st, 2017

Can precision medicine and protocols coexist?
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Marc Iravani, MD

Three of our faculty physicians are featured on the latest cover of Anesthesia & Analgesia for their thoughtful article, “Bridging the gap between standardized care and precision medicine.”

Marc Iravani, MD, Lisa Lee, MD, and Maxime Cannesson, MD, PhD, analyzed the tension between:

  • the need to develop reproducible, efficient protocols for health care, as advocated by initiatives such as the Perioperative Surgical Home and Enhanced Recovery After Surgery;
  • the equally compelling need to use the tools of genetics and genomics to provide patients with individualized “precision” health care.
 
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Current Perioperative Workflow vs. Potential Contributions of Genomic Testing to the Perioperative Workflow

The authors reviewed real-life clinical examples where genetic differences have altered reactions to medications, sometimes with fatal results. For instance, some children metabolize codeine very rapidly. They are at risk of life-threatening respiratory depression, if given routine doses of codeine after surgery, because they develop toxic levels of morphine in their blood. Patients who are resistant to the antiplatelet effects of clopidogrel (Plavix) may be at increased risk for stroke, myocardial infarction, or in-stent thrombosis if they need antiplatelet therapy.

“As our understanding of differential drug metabolism improves, this pharmacogenetic knowledge will need to be incorporated into clinical practice,” the authors wrote. Fortunately, point-of-care (POC) testing is becoming better and faster. Patients could undergo targeted genetic testing during preoperative visits, enabling precise selection of medications for intraoperative and postoperative management depending on the findings.

Working with UCLA’s new Institute for Precision Medicine, our department is partnering in an initiative to gather a blood sample for genomic analysis from every patient who presents for surgery. This enormous data bank will be linked with outcomes data from our electronic health system. The goal is to identify groups of patients at genomic risk for complications such as stroke, myocardial infarction, kidney injury, arrhythmias, cognitive decline, and sepsis.

“In the future, as the genomes of more patients are sequenced, the information can be integrated permanently into the medical record and alerts can be raised” whenever a medication should be avoided or a different type of treatment initiated, the authors concluded. “Such advancements in precision medicine provide opportunities to bring patient-centered care back to the forefront as a more standardized model of anesthetic care is taking shape through the efforts of the Perioperative Surgical Home and Enhanced Recovery models of care.”

 



--Karen Sibert, MD
 

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